The Paula method and the pelvic floor: reply by the authors 2

Abstract

Dear Editor, We are pleased to read that Liebergall-Wischnitzer agrees that pelvic floor muscle training (PFMT) is effective and should be recommended as level A evidence for pelvic floor dysfunction [1]. Although in a previous paper, he and colleagues claim that the Paula method is superior in terms of cure rate (p. 377) [2]. We used surface electromyography to evaluate the pelvic floor muscle (PFM) activation during the contraction of circular muscles (Paula method). In nulliparous women, these exercises did not increase PFM activation. In two previous papers by Liebergall-Wischnitzer et al. [2, 3], patients included in the Paula group practiced, besides contraction of circular muscles, PFM voluntary contraction in a weekly individual 45-minute sessions for 12 weeks and were encouraged to practice daily for 45 min at home (p.378) [2]. Patients included in the PFMT group did structured exercise program in groups of 1–10 people for 30 min once weekly for 4 weeks, followed by two more lessons 4 weeks apart each (overall six lessons) (p.378) [2]. How can one compare so distinct training programs? Actually, the patients in both groups practiced PFMT in different proportions. What is the benefit of adding circular muscle contractions? It is well established that supervised training significantly improves the results of PFMT [4, 5]. The only way to investigate if circular contractions are more effective than the PFMT alone is to do a head-to-head assessor blinded RCT with the same training dosage and therapist contact in both arms, or add the new concept to current practice in one arm. According to Liebergall-Wischnitzer’s letter [1], PFM strength is not a desirable outcome of Paula exercises, but according to Liebergall-Wischnitzer et al. in 2005, exercising the ring muscles in a certain area of the body will result in strengthening the circular muscles in other areas (p. 345) [3]. With this phrase, we understood that strengthening was the main goal of Paula exercises. At first, how can you be sure that any circular muscle contraction leads to contraction of the others? What are the evidences for that? If this is proven, could external sphincter ani contract alone? Or PFM will be recruited too? How could the external sphincter ani be strengthened and not the PFM? Liebergall’s letter also said that when contracting the eyes/mouth and the PFM, co-contraction is not a reflex, but training is required. After a training period, the trainee begins to feel that these muscles can work together and naturally integrate with PFMT. However, in the article they say “The theory that lies behind the Paula method is that all sphincters in the human body work simultaneously, mutually affecting one another possibly mediated by oscillation of the spinal cord” (p. 345) [3]. If they naturally affect one another because of spinal cord oscillation, how could the spinal cord be trained? If it could be trained, how long this training is necessary to these muscles work together? Moreover, if a patient is taught to contract PFM during some exercises such as Pilates and yoga, with some A. P. M. Resende (*) :C. D. Petricelli : S. M. Alexandre : M. U. Nakamura :M. R. D. Zanetti Obstetrics Department, Federal University of Sao Paulo, Rua Napoleao de Barros, 875, Sao Paulo 04024–002, Brazil e-mail: anapaulamrb@gmail.com