*5.1.1 Animated pelvic floor EMG biofeedback*

Mc Kenna et al. in 1999 applied biofeedback in the form of interactive computer games that enabled the active participation of patients [44]. Computer play maintained the child's interest and motivation for the exercise programme. The method consists of placing superficial EMG electrodes on the child's perineum, and then the child is taught to properly contract and relax the PFMs by watching a game on a computer monitor. In this way, children become aware of the activity of the PFMs and learn to control them by controlling the activities of their favorite heroes (dolphin, monkey, fish, bee).

In a study by Herndon et al. interactive computer games were used in 160 children with DV [45]. In 87% of patients, subjective improvement of symptoms was achieved. In a study by McKenna et al. improvement of nocturnal enuresis was achieved in 90%, daily wetting in 89%, constipation and fecal incontinence in 100% [44].

Kaye and Palmer did not find significant differences in efficacy after application of non-animated (biofeedback without animation using only EMG tracing) and animated biofeedback [46]. However, a group of children who had animated biofeedback required a smaller number of sessions to normalize the uroflowmetry curve and reduce residual urine. In a study by Desantis et al. there was an improvement in urinary tract infections in 83%, diurnal incontinence in 80%, constipation from 18–100%, urinary frequency from 67–100%, urgency from 71–88% and VUR from 21–100% of children [47].

In a study by Palmer et al. in children with DV and VUR, the use of biofeedback accelerated the resolution of VUR or reduced the degree of VUR in 71% of children [48]. Similar results were presented by Khen-Dunlop et al. and Kibar et al. [49, 50]. Adequate patient selection seems to be the most important for biofeedback success. Parents and children should be motivated and compliant to continue practicing exercises at home [51].

Although numerous studies highlight the positive effects of PFM relaxation exercises with or without biofeedback, there is no clear recommendation of an exercise protocol to use in the rehabilitation of children with DV. The number of sessions, the number of repetitions, the duration of the contraction and relaxation phase, as well as the period of performing the exercises differ significantly between the studies.

De Paepe et al. applied PFM relaxation exercises with EMG biofeedback [52]. The protocol consisted of 30 submaximal contractions lasting 3 seconds, followed by a relaxation phase of 30 seconds. One session per week was applied for 6 months (maximum 20-24 sessions). In a study by Vasconcelos et al., 24 home exercise sessions lasting 20 minutes were applied, three times a week during a three-month period [53]. The contractions lasted for 5 seconds, followed by a 10-second relaxation period. Shei Dei increased the duration of contractions to 10 seconds and extended the relaxation period to 30 seconds [54]. Yagci et al. applied submaximal contractions of 3 seconds, followed by a relaxation period of 30 seconds [55]. The children repeated the exercises at home three times a day for 6 months. In a retrospective study, Drzeviecki et al. analyzed a programme in which the contractions lasted 10 seconds, followed by a relaxation of 10 seconds [56]. After that, fast contractions lasting 5 seconds and 5 seconds of relaxation followed. On average, 3 sessions (1-8) were applied.

#### **5.2 Abdominal capsule**

Sapsford et al. showed that the PFMs are not an isolated unit, but a part of the abdominal capsule that surrounds the abdominal and pelvic organs [57]. The structures that make this capsule are the lumbar vertebrae, *M. multifidus*, diaphragm, *M. transversus abdominis* and PFMs. These muscles contribute to maintaining the posture of the body in an upright position and act synergistically.

Coactivation of the abdominal and PFMs is necessary for the development of intra-abdominal pressure and contributes to the stability of the spine. It is shown that *M. transversus abdominis* contributes the most to the development of intraabdominal pressure in relation to other abdominal muscles [58]. This muscle is first activated during functions related to the increase in intra-abdominal pressure, such as spinal stabilization and expiratory tasks [58]. Coactivation of the abdominal capsule muscles has been demonstrated during weight lifting, coughing and forced expiratory tasks [58, 59].

Pelvic floor muscle dysfunction can present as hyperactivity, leading to the development of voiding and defecation disorders, such as DV, chronic constipation, perianal and perineal pain. Many of these children have hyperactivity of the lower abdominal muscles, which do not relax during urination and defecation and thus prevent the relaxation of the PFMs [57].

#### **5.3 Diaphragmatic breathing exercises**

As lower abdominal muscles (*M. transversus abdominis* and *M. obliquus internus abdominis*) and PFMs act synergistically, it is necessary for them to relax together during urination and defecation.

The simplest way for children to learn how to relax their abdominal muscles is through diaphragmatic breathing exercises. During diaphragmatic breathing, in inspiration, the diaphragm moves caudally and pushes the abdominal organs

### *Rehabilitation Protocols for Children with Dysfunctional Voiding DOI: http://dx.doi.org/10.5772/intechopen.98573*

forward. The anterior abdominal wall relaxes, as do the PFMs. This forward bulging of the anterior abdominal wall has been shown to reduce urethral pressure in healthy women and thus facilitate urination and defecation [58] .

Our institution was the first to incorporate this novel approach to treating DV. In a prospective clinical study of 43 children, in addition to standard urotherapy that included education on the importance of regular urination and hydration, proper voiding position and pattern, diaphragmatic breathing exercises and PFM relaxation exercises were performed in hospital settings for two weeks and then continued at home [60].

Diaphragmatic breathing exercises were performed in a supine position with the lower extremities supported by a pillow and hands placed on the abdominal muscles. The patient is required to inhale air through the nose, expel the anterior abdominal wall, hold the breath for a few seconds, and then exhale the air through the mouth (**Figures 4** and **5**). The exercises were repeated in both lateral positions, in the prone position, and then in the sitting position in front of the mirror (**Figure 6**). Children are required to observe the anterior abdominal wall during inspiration and then apply this exercise before urinating and defecating.

In addition, exercises for relaxation of the PFMs were performed. The child was placed in a lateral position with the upper leg flexed at the hip and knee and the lower leg extended. To enhance the proprioception of the PFMs, the examiner placed two fingers on the child's perineum and demanded that the child contract the PFMs without activating adjacent muscles such as the gluteus and hip adductor muscles. In this way, the child learned to localize and control the PFMs. The child was then required to perform submaximal contractions for 3 seconds followed by prolonged relaxation for about 30 seconds, for a total of 20 contractions. Children are required to perform these exercises daily at home for 6 months.

Control examinations were performed monthly for 12 months. Clinical manifestations (daytime urinary incontinence, nocturnal enuresis, urinary tract infections,

**Figure 4.** *Diaphragmatic breathing exercises in supine position (expiration).*

**Figure 5.** *Diaphragmatic breathing exercises in supine position (inspiration).*

**Figure 6.** *Diaphagmatic breathing exercises in front of the mirror.*

constipation) were analyzed on a monthly basis and uroflowmetry was performed. The performance of diaphragmatic breathing exercises was controlled and the importance of daily exercise at home was emphasized. The children are encouraged to continue with the treatment.

After one year of monitoring and treatment, reevaluation of clinical manifestations and uroflowmetry parameters was performed. Urinary incontinence was cured in 83% of children, nocturnal enuresis in 63%, and urinary tract infections

### *Rehabilitation Protocols for Children with Dysfunctional Voiding DOI: http://dx.doi.org/10.5772/intechopen.98573*

in 68%. Chronic constipation was cured in all 15 patients. In addition, an objective improvement in uroflowmetry parameters was achieved. A normal uroflowmetry curve was registered in 90% of children.

The authors suggested that examination of lower abdominal muscles, recognition of their function during voiding and their relaxation should be incorporated in the treatment program of these children. Easy to learn diaphragmatic breathing exercises did not require any specific equipment and could be performed in children from five years of age. For centres that do not have access to pelvic floor EMG biofeedback, this programme could provide a treatment alternative as success rates are comparable to previous studies that used pelvic floor EMG biofeedback during urotherapy [54–56]. In order to achieve subjective and objective progress, children needed an average of 6.5 sessions, which is also equivalent to the average number of sessions in programmes that included non-animated biofeedback [46].

In the following study, the effects obtained in this group were compared with the effects in the group of children treated only with standard urotherapy (32 children) [31]. The children had 10 sessions of urotherapy in a hospital setting, and then were required to continue with it at home. After one year of follow-up, cure of urinary incontinence was achieved in only two children, nocturnal enuresis in 5, and urinary tract infections in 6 children. Constipation was cured in 6 out of 10 children. Uroflowmetry parameters did not show significant improvements. The authors concluded that diaphragmatic breathing exercises and PFM relaxation exercises, in combination with standard urotherapy, are important for the treatment of daily urinary incontinence, nocturnal enuresis and urinary tract infections, as well as for normalizing bladder function in children with DV.

## **5.4 Pharmacological therapy**

Pharmacological therapy is considered an adjunct to improve bladder emptying in children with DV [43].
