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Manzotti A, Fumagalli S, Zanini S, Brembilla V, Alberti A, Magli I, Buratti E, Coraglia N, De Fusco A, Zambù D, Zanotta V, Nespoli A. What is known about changes in pelvic floor muscle strength and tone in women during the childbirth pathway? A scoping review. Eur J Midwifery 2024; 8:EJM-8-42. [PMID: 39099673 PMCID: PMC11295251 DOI: 10.18332/ejm/189955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/04/2024] [Accepted: 06/12/2024] [Indexed: 08/06/2024] Open
Abstract
INTRODUCTION This scoping review aims to comprehensively explore the existing research on the changes in pelvic floor function that occur throughout the childbirth pathway (antenatal, intrapartum, and postnatal period). Furthermore, it seeks to identify new opportunities and directions for future research in this field. In particular, this review focuses on investigating pelvic floor muscle strength and tone in women during the childbirth pathway. METHODS The following databases were investigated from their inception: PubMed, OVID, Medline, ScienceDirect, The Cochrane Central Library, Scopus, Web of Science, PEDro, Scholar Google, Embase, and CINHAIL. Literature research was carried out from March to October 2022. Records identified through database searching were imported to Covidence. According to Arksey and O'Malley's five-stage scoping review framework, researchers screen titles and abstracts for eligibility and exclude records that do not meet the inclusion criteria. RESULTS A total of 40 studies were included in the data extraction phase. These articles underwent a review, with a specific emphasis on examining the tone, strength, and distensibility of the pelvic floor throughout the childbirth pathway. Among the selected studies, 22 investigated pelvic floor strength, 7 the distensibility, and 3 articles the tone. CONCLUSIONS This review identified both areas of agreement and disagreement across all three themes examined, with a particular emphasis on labor and the postpartum period. Notably, the review unveiled a significant scarcity of data concerning the tone of pelvic floor muscles throughout the childbirth pathway. Further studies to investigate the relationship between midwifery care and pelvic floor outcomes are required to improve clinical practice.
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Affiliation(s)
- Andrea Manzotti
- RAISE Lab, Clinical-Based Human Research Department, Foundation COME Collaboration, Pescara, Italy
- Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
| | | | - Sonia Zanini
- RAISE Lab, Clinical-Based Human Research Department, Foundation COME Collaboration, Pescara, Italy
- Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
| | - Veronica Brembilla
- Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
- University of Milano-Bicocca, Monza, Italy
| | - Adele Alberti
- Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
| | - Ilaria Magli
- Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
| | - Elis Buratti
- Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
| | | | - Andrea De Fusco
- Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
| | - Daniel Zambù
- Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
| | - Valeria Zanotta
- Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
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Cabral AL, de Freitas SS, Pinto RDMC, Resende APM, Pereira-Baldon VS. Are Perineal Massage and Instrument-Assisted Perineal Stretching With Short Protocol Effective for Increasing Pelvic Floor Muscle Extensibility? A Randomized Controlled Trial. Phys Ther 2022; 102:6544340. [PMID: 35258595 DOI: 10.1093/ptj/pzab305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/11/2021] [Accepted: 11/21/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The purpose of this study was to compare (1) the effects of the instrument-assisted perineal stretching technique with different application protocols in combination with perineal massage and (2) the effects of the isolated techniques on the extensibility and strength of the pelvic floor muscles (PFMs). METHODS A randomized controlled clinical trial with parallel randomization, assessor blinding, and concealed allocation was conducted in the Campus Physical Education at the Federal University of Uberlândia in Brazil. Ninety-six pregnant women (18-40 years of age) were allocated into 4 groups: perineal massage (PnM) group (PnM protocol for 10 minutes); instrument-assisted perineal stretching with a long static protocol for 15 minutes [IStrLS group]); PnM + IStrLS group (both techniques applied in the 2 previous groups); and PnM + IStrSR group (the same techniques as used in the PnM + IStrLS group but with a short repeated protocol; 4 sets lasting 30 seconds each). Eight interventions were performed in all 4 groups twice weekly (beginning at the 34th gestational week). The primary outcome was PFM extensibility, assessed using vaginal dilator circumference, and the secondary outcome was PFM strength, assessed using vaginal manometry. RESULTS For the PFM extensibility variable, a significant main effect of time (F2,88 = 87.951) and group (F3,88 = 7.193) was found. Tukey post hoc test results showed that the PnM + IStrSR group presented greater extensibility than the PnM and IStrLS groups. The PnM group showed increased PFM strength after 8 sessions compared with the other groups. CONCLUSIONS Women who were pregnant and received the combination of perineal massage and instrument-assisted perineal stretching with short repeated application had a greater increase in PFM extensibility than perineal massage and instrument-assisted perineal stretching alone. IMPACT The combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol led to better PFM extensibility results than the application of the techniques alone in women who were pregnant. LAY SUMMARY Pregnant women can benefit from intervention using the combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol.
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Affiliation(s)
- Alana Leandro Cabral
- Postgraduate Program in Health Sciences, Federal University of Uberlândia, Uberlândia, MG, Brazil
| | - Síssi Sisconeto de Freitas
- Physical Therapy Postgraduate Program, Federal University of Triângulo Mineiro associated with Federal University of Uberlândia, Uberlândia, MG, Brazil
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Wu S, Nitschke K, Worst TS, Fierek A, Weis CA, Eckstein M, Porubsky S, Kriegmair M, Erben P. Long noncoding RNA MIR31HG and its splice variants regulate proliferation and migration: prognostic implications for muscle invasive bladder cancer. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2020; 39:288. [PMID: 33334367 PMCID: PMC7745499 DOI: 10.1186/s13046-020-01795-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023]
Abstract
Background Growing evidence supports the pivotal role of long non-coding RNAs (lncRNAs) in the regulation of cancer development and progression. Their expression patterns and biological function in muscle invasive bladder cancer (MIBC) remain elusive. Methods Transcript levels of lncRNA miR-31 host gene (MIR31HG) and its splice variants were measured in our MIBC cohort (n = 102) by qRT-PCR, and validated in silico by the TCGA cohort (n = 370). Kaplan-Meier and multiple Cox regression analysis were conducted to evaluate the survival significance of MIR31HG and its splice variants. Functional experiments were performed to examine the proliferation and migration abilities of MIR31HG and its splice variants by knockdown approaches. Results In this study, a decreased expression of MIR31HG was found in bladder cancer cells and tissues, except in the basal subtype. Survival analysis showed that high expression of MIR31HG was associated with poor overall survival (OS) and disease-free survival (DFS) in patients with MIBC of basal subtype. Two splice variants of MIR31HG lacking exon 1 (MIR31HGΔE1) and exon 3 (MIR31HGΔE3) were identified to have specific expression patterns in different molecular subtypes of our MIBC cohort. MIR31HGΔE3 was highly expressed in basal subtype tumors. A high expression of MIR31HGΔE1 and MIR31HGΔE3 was associated with worse OS and DFS in our cohort. In vitro experiments revealed that knockdown of MIR31HG inhibits cell proliferation, colony formation, and migration in bladder cancer. Cell proliferation and migration assays after knockdown of splice variants of MIR31HG showed corresponding roles for the full-length transcript. Conclusions Our study demonstrates that MIR31HG and its splice variants could serve as biomarkers for the classification and prognosis prediction of patients with MIBC. Supplementary Information The online version contains supplementary material available at 10.1186/s13046-020-01795-5.
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Affiliation(s)
- Sheng Wu
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167, Mannheim, Germany.,Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, Anhui, China
| | - Katja Nitschke
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Thomas Stefan Worst
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Alexander Fierek
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Cleo-Aron Weis
- Institute of Pathology, Medical Faculty Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Markus Eckstein
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91052, Erlangen, Germany
| | - Stefan Porubsky
- Institute of Pathology, Medical Faculty Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Maximilian Kriegmair
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Philipp Erben
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
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Kubotani JS, Zanetti MRD, Araujo Júnior E, Passos JP, Elito Júnior J. Transperineal three-dimensional ultrasound for analyzing the effects of perineal stretching with EPI-NO ® in women with multiple pregnancies: a pilot study. J Matern Fetal Neonatal Med 2020; 35:283-290. [PMID: 32024410 DOI: 10.1080/14767058.2020.1716716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To compare the changes in the pelvic floor of women with twin pregnancies who practiced muscle stretching with the EPI-NO® vaginal dilator, as assessed using transperineal three-dimensional ultrasound (3DUS).Method: This prospective cross-sectional case-control study included nulliparous women in the third trimester of their multiple pregnancies and divided them into the control group (CG, n = 9) and EPI-NO® group (EpiG, n = 9). During pretreatment, the women underwent transperineal 3DUS to establish the morphometric measurements of the pelvic floor. The CG received guidance regarding pelvic floor muscles, whereas the EpiG underwent weekly physical therapy sessions with the EPI-NO® dilator for 20 min/day. Following this treatment, all women were reassessed using transperineal 3DUS, and the diameter of the EPI-NO® balloons of the women in the EpiG was measured (epinometry). Paired samples t-test was used for comparative analysis.Results: The EpiG showed improved perineal distensibility, which was evidenced by the increase in sagittal diameter at rest (p < .01). Transperineal 3DUS among women in the EpiG showed a significant increase in the sagittal measurement (p = .02), hiatal circumference at rest (p = .03), and epinometry values (diameter of the EPI-NO® balloon; p < .01). The increase in epinometry values was directly correlated (p = .02) with the number of physical therapy sessions.Conclusion: EPI-NO® increased pelvic floor distensibility in women with twin pregnancies, as confirmed using transperineal 3DUS and epinometry. This device promoted an increase in perineal distensibility with a single use; however, better results would be obtained with additional sessions.
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Affiliation(s)
- Juliana Sayuri Kubotani
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Miriam Raquel Diniz Zanetti
- Department of Science of Human Movement, Physical Therapy Course, Federal University of São Paulo (UNIFESP), Santos, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Jurandir Piassi Passos
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Julio Elito Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
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Wu S, Nitschke K, Heinkele J, Weis CA, Worst TS, Eckstein M, Porubsky S, Erben P. ANLN and TLE2 in Muscle Invasive Bladder Cancer: A Functional and Clinical Evaluation Based on In Silico and In Vitro Data. Cancers (Basel) 2019; 11:E1840. [PMID: 31766561 PMCID: PMC6966660 DOI: 10.3390/cancers11121840] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 01/09/2023] Open
Abstract
: Anilin actin binding protein (ANLN) and transducing-like enhancer protein 2 (TLE2) are associated with cancer patient survival and progression. The impact of their gene expression on progression-free survival (PFS) of patients with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) and subtype association has not yet been investigated. qRT-PCR was used to measure the transcript levels of ANLN and TLE2 in the Mannheim cohort, and validated in silico by The Cancer Genome Atlas (TCGA) cohort. Uni- and multivariate Cox regression analyses identified predictors for disease-specific survival (DSS) and overall survival (OS). In the Mannheim cohort, tumors with high ANLN expression were associated with lower OS and DSS, while high TLE2 expression was associated with a favorable OS. The TCGA cohort confirmed that high ANLN and low TLE2 expression was associated with shorter OS and disease-free survival (DFS). In both cohorts, multivariate analyses showed ANLN and TLE2 expression as independent outcome predictors. Furthermore, ANLN was more highly expressed in cell lines and patients with the basal subtype, while TLE2 expression was higher in cell lines and patients with the luminal subtype. ANLN and TLE2 are promising biomarkers for individualized bladder cancer therapy including cancer subclassification and informed MIBC prognosis.
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Affiliation(s)
- Sheng Wu
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (S.W.); (K.N.); (J.H.); (T.S.W.)
| | - Katja Nitschke
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (S.W.); (K.N.); (J.H.); (T.S.W.)
| | - Jakob Heinkele
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (S.W.); (K.N.); (J.H.); (T.S.W.)
| | - Cleo-Aron Weis
- Institute of Pathology, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (C.-A.W.); (S.P.)
| | - Thomas Stefan Worst
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (S.W.); (K.N.); (J.H.); (T.S.W.)
| | - Markus Eckstein
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91052 Erlangen, Germany;
| | - Stefan Porubsky
- Institute of Pathology, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (C.-A.W.); (S.P.)
| | - Philipp Erben
- Department of Urology and Urosurgery, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (S.W.); (K.N.); (J.H.); (T.S.W.)
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Paschoal A, Uchiyama Nakamara M, Araujo Júnior E, Petricelli CD, Alexandre SM, Zanetti MRD. Device to predict pelvic floor integrity during vaginal delivery: an intra- and interrater reliability study of the Epi-no distensibility measurement. J Matern Fetal Neonatal Med 2019; 34:3481-3487. [PMID: 31718332 DOI: 10.1080/14767058.2019.1685970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To determine the test-retest reliability of the pelvic floor distensibility evaluation with Epi-no® device.Methods: Prospective, blinded observational study with 32 women pregnant from 35 gestational weeks. An Epi-no® balloon was inflated within the pregnant woman's vagina and the maximum circumference achieved was measured using a standard metric measuring tape. Measurements were performed twice in a day by two physiotherapists in a randomized order. Intraobserver reproducibility was obtained with another evaluation 7-14 d after the initial examination. The intraclass correlation coefficient (ICC) was used to determine the intra and interrater reliability and the respective 95% confidence intervals with an alpha level of 0.05.Results: From a total of 32 included pregnant women, 28 were analyzed; they were 29.3 (±5.97) years old, were at 37 (±1.3) weeks' gestation and presented a mean Epi-no® circumference of 20.4 (±2.4) cm. Regarding the intraobserver analysis, examiner 1 observed a maximum circumference of 20.6 (±2.6) cm in the first evaluation and 20.2 (±2.4) cm in the second evaluation, with good reliability (ICC = 0.85). Examiner 2 observed 19.7 (±2.4) cm in the first evaluation and 21.0 (±2.0) cm in the second one, with moderate reliability (ICC = 0.58). Regarding the interobserver analysis, there was good reliability on two evaluation days, with an ICC of 0.76 and 0.82, respectively.Conclusions: Epi-no® device is a reliable device for physiotherapists to measure pelvic floor distention during pregnancy.
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Affiliation(s)
- Aline Paschoal
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Mary Uchiyama Nakamara
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Carla Dellabarba Petricelli
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Sandra Maria Alexandre
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Miriam Raquel Diniz Zanetti
- Department of Science of Human Movement, Physical Therapy Course, Federal University of São Paulo (UNIFESP), Santos, Brazil
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Paschoal A, Zanetti MRD, Petricelli CD, Alexandre SM, Araujo Júnior E, Nakamura MU. Quantitative assessment of pelvic floor muscle extensibility in pregnant women with a perineal elasticity meter. J Matern Fetal Neonatal Med 2019; 33:3591-3595. [PMID: 30724673 DOI: 10.1080/14767058.2019.1579792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The objective of this study was to compare measurements of pelvic floor muscle extensibility in pregnant women obtained through the Epi-no® and perineal elasticity meter (PEM) devices.Methods: This was an observational, cross-sectional study with a consecutive sample, conducted in a prenatal care outpatient clinic. The pelvic floors of 62 healthy pregnant women with gestational ages between 35 and 40 weeks were assessed. Perineal extensibility was measured using the Epi-no® and PEM devices. Through the linear regression method, a formula was created to calculate the Epi-no® values from the PEM values. To determine the degree of relationship between both variables, Pearson's correlation coefficient was used.Results: In the comparison of the results for 62 pregnant women using the two perineal extensibility assessment methods, the value obtained in the Pearson correlation coefficient analysis (0.621) indicated a moderate relationship between the variables. This finding was not confirmed by the Kappa correlation test. When the measurements were classified into three groups, a slight correlation was identified (perineum with restrictions, moderate extensibility, and good extensibility).Conclusion: There was a relationship between Epi-no® and PEM from slight to moderate agreement.
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Affiliation(s)
- Aline Paschoal
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Miriam Raquel Diniz Zanetti
- Department of Management and Health Care, Baixada Santista Campi - Federal University of São Paulo (UNIFESP), Santos, Brazil
| | - Carla Dellabarba Petricelli
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Sandra Maria Alexandre
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Mary Uchiyama Nakamura
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
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Effects of perineal preparation techniques on tissue extensibility and muscle strength: a pilot study. Int Urogynecol J 2018; 30:951-957. [PMID: 30343376 DOI: 10.1007/s00192-018-3793-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/10/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Perineal preparation techniques for childbirth have been used with the aim of reducing perineal tears during the expulsive phase of labor. However, no studies were found to investigate the effects of instrument-assisted stretching versus perineal massage on pelvic floor muscle (PFM) variables. Therefore, the aim of this study was to evaluate the effect of instrument-assisted stretching versus perineal massage on the extensibility and strength of the PFMs. METHODS Primiparous women were randomized to the instrument-assisted stretching (IStr) group (n = 13) and perineal massage (PnM) group (n = 14). The groups participated in eight sessions, twice weekly, beginning at the 34th gestational week. The IStr group underwent the intervention for 15 min using EPI-NO®. The PnM group underwent a perineal massage protocol for 10 min. Each woman was evaluated by a blinded physiotherapist before, after four and after eight sessions for primary (PFM extensibility using the EPI-NO® circumference) and secondary (PFM strength using a manometer) outcomes. Covariate analysis (ANCOVA) was used to compare the groups using the baseline values as a covariate. RESULTS Both groups showed an increase in PFM extensibility compared with the evaluations before and after four and eight sessions (PnM group from 17.6 ± 1.8 to 20.2 ± 1.9 cm; IStr group from 19.9 ± 1.6 to 22.9 ± 1.6 cm;p < 0.001). There was no difference between groups. Regarding muscle strength, no statistical differences were observed between evaluations or between groups. CONCLUSIONS Instrument-assisted stretching and perineal massage increase extensibility and do not alter the strength of PFMs in pregnant women.
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