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Title: Ankle positions potentially facilitating greater maximal contraction of pelvic floor muscles : a systematic review and meta-analysis
Authors: Kannan, P 
Winser, S 
Goonetilleke, R
Cheing, G 
Issue Date: 2019
Source: Disability and rehabilitation, 2019, v. 41, no. 21, p. 2483-2491
Abstract: Objectives: To evaluate the effect of ankle positions on pelvic floor muscles in women.
Methods: Multiple databases were searched from inception-July 2017. Study quality was rated using the grading of recommendations, assessment, development, and evaluation system and the “threats to validity tool”.
Results: Four studies were eligible for inclusion. Meta-analysis revealed significantly greater resting activity of pelvic floor muscles in neutral ankle position (−1.36 (95% CI −2.30, −0.42) p =  0.004) and induced 15° dorsiflexion (−1.65 (95% CI −2.49, −0.81) p =  0.0001) compared to induced 15° plantar flexion. Significantly greater maximal voluntary contraction of pelvic floor was found in dorsiflexion compared to plantar flexion (−2.28 (95% CI −3.96, −0.60) p =  0.008). Meta-analyses revealed no significant differences between the neutral ankle position and 15° dorsiflexion for either resting activity (0.30 (95% CI −0.75, 1.35) p =  0.57) or maximal voluntary contraction (0.97 (95% CI −0.77, 2.72) p =  0.27).
Conclusion: Pelvic floor muscle-training for women with urinary incontinence could be performed in standing with ankles in a neutral position or dorsiflexion to facilitate greater maximal pelvic floor muscle contraction. As urethral support requires resting contraction of pelvic floor muscles, decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with urinary incontinence might potentially experience more leakage during exertion in a standing position.
•Implications for rehabilitation
•Pooled analyses revealed that maximal voluntary contraction of pelvic floor muscle is greater in induced ankle dorsiflexion than induced plantar flexion.
•As pelvic floor muscle strengthening involves achieving a greater maximal voluntary contraction, pelvic floor muscle training for women with stress urinary incontinence could be performed in standing either with ankles in a neutral position or dorsiflexion.
•Decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with stress urinary incontinence might potentially experience more leakage during exertion in a standing position.
•Women with stress urinary incontinence should be advised to wear flat shoes instead of high-heels and should be cautioned about body posture and ankle positions assumed during exercise and daily activities.
Keywords: Ankle positions
Pelvic floor muscles
Stress urinary incontinence
Systematic review
Publisher: Taylor & Francis Group
Journal: Disability and rehabilitation 
ISSN: 0963-8288
EISSN: 1464-5165
DOI: 10.1080/09638288.2018.1468934
Rights: © 2018 Informa UK Limited, trading as Taylor & Francis Group
This is an Accepted Manuscript of an article published by Taylor & Francis in Disability and Rehabilitation on 07 May 2018 (Published online), available online: http://www.tandfonline.com/10.1080/09638288.2018.1468934.
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