Your study followed gymnasts for eight months, one of the longest durations in pelvic floor muscle training (PFMT) research. Low adherence was noted as a potential limitation, as only 62 per cent of gymnasts completed 65 per cent or more of the sessions. What strategies could be implemented to improve adherence in young, high-performance athletes? 

The PFMT was supposed to be conducted during an extended warm-up program at every training session. 

However, the degree of coach supervision while conducting the warm-up varied between the rhythmic gymnastics clubs in our trial, making some of the gymnasts responsible for carrying out the PFMT themselves. 

Given that the gymnasts in our trial were young, with generally little knowledge of the pelvic floor, they may have failed to see the benefits of PFMT—especially if they were symptom-free during the trial. 

With numerous high-impact elements and repetitive increases in intra-abdominal pressure in rhythmic gymnastics, there will always be a risk of developing urinary incontinence (UI). 

Increased supervision of PFMT by the coach may be an option to improve adherence, for both prevention and treatment, in future practice and research. 

Despite no significant reduction in UI bother or prevalence, 82 per cent of gymnasts reported a perceived benefit from PFMT. 

How do you interpret this discrepancy between subjective and objective findings? 

UI has been, and still is, taboo within rhythmic gymnastics. 

During my visits to the clubs in the experimental group, many of the gymnasts expressed gratitude that we were targeting UI. 

Several gymnasts had previously dealt with their symptoms on their own because UI can be seen as embarrassing. 

My impression was that several gymnasts found the trial positive because they had the chance to learn about the pelvic floor, how to activate it correctly and that properly performed PFMT can prevent and treat UI. 

Some of the gymnasts may perceive this new knowledge as empowering and helpful in both normalising and trivialising an otherwise embarrassing condition. 

Alternatively, they may have genuinely felt a difference, eg, that they strengthened their pelvic floor muscles after eight months of PFMT, causing a sense of perceived benefit regardless of any symptoms. 

Marte Dobbertin Gram is researching whether an extended warmup can reduce urinary incontinence in elite rhythmic gymnasts

You mention that one-to-one supervised PFMT might be necessary for rhythmic gymnasts. How feasible is this in real-world training environments and what alternatives could be considered? 

One-to-one supervised PFMT is time-consuming and only feasible as a targeted treatment in real-world training environments for gymnasts that already experience bothersome UI symptoms. 

For symptom-free gymnasts, PFMT led by the coach and performed during warm-up at every training session is the only feasible alternative. 

This is due to the heavy work burden in this specific group of young, high-level athletes. 

The combination of schoolwork, high weekly training load and competitions every weekend would make adding more to this equation difficult. 

Your study included additional lower back and lower limb exercises in the intervention. Do you think these could have influenced the results, either positively or negatively? 

No, we don’t think so, but of course we cannot be 100 per cent sure due to the study design we chose. 

For those who are interested in more details on this subject, we discuss this thoroughly in our publication—with references to the existing literature highlighting pros and cons. 

Given that UI in young gymnasts may be an early indicator of future pelvic floor dysfunction, what are the next research priorities in this field? 

Future research should focus on conducting a randomised controlled trial to observe the effect of increased coach supervision during PFMT on bother and prevalence of UI symptoms. 

In addition, it would be valuable to conduct a follow-up study to assess whether systematic PFMT during a gymnast’s sporting career affects their pelvic floor dysfunction later in life. 

>>Marte Dobbertin Gram is a physiotherapist and PhD candidate at the Norwegian School of Sport Sciences. With a background as a high-level rhythmic gymnast, she is currently working as the Norwegian rhythmic gymnastics national team’s physiotherapist in addition to being a researcher. 

Click here to read the paper. 

Course of interest: 

Evidence for increased tone/overactivity of pelvic floor muscles in pelvic health conditions