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Recap: 'Survivor: Blood vs. Water' - 'Out On a Limb'
Is Monica about to become a key swing vote?
Pre-credit sequence. We begin on Redemption Island, as Katie arrives after her ill-fated rock-draw. Tina is happy to see her daughter, but sad that she's on Redemption. Katie gives a blow-by-blow on the rocking and both Tina and Laura agree that Katie did the right thing by taking her fate into her own hands, kinda. Even if she sorta stumbled into the rocks. "I would not be opposed to letting you win," Tina tells Katie about the upcoming Duel. "It's my daughter and that takes precedence over all things, even a million dollars," says Tina, who has previously won a million dollars.
Also, never get involved in a land war in Asia. Things are nutty as folks return to camp. Tyson is still reeling. Hayden is apologizing and saying he loves people. While things failed for his alliance, Hayden's gambit at Tribal Council worked for him individually, so he's pleased, but not as pleased as if Tyson had gotten the wrong rock. "That's why you don't let an insane person know that they're the next to go, Gervase," Tyson says, debriefing his alliance-mate. "You have to give them home. You have to tell them somebody else's name," Tyson says. As of now, Monica is relieved that her alliance stuck with her. Don't worry, she'll forget that relief. Monica worries, though, that if either Tyson or Gervase has an Idol, she could be in trouble. To shut her up, Tyson reveals to her that he has an Idol, but that doesn't calm Monica, who worries that she doesn't have any respect. "It hurt me and I'll never forget it," Monica vows. "She's not great at 'Survivor,' but she's really come in handy," Tyson cackles to Gervase.
I got nothing to lose, much to gain/ In my brain, I got a capitalist migraine. For some reason, Ciera is feeling relief after her performance at the last Tribal. She's glad that, if nothing else, she made a move. Suddenly, Ciera wants Laura back in the game. She also wants an Idol and to win a challenge. Anything, really. "The great thing about my position right now is I have nothing to lose," she says.
Sniffle. Duel time! Tina, Laura and Katie arrive at Redemption Island Arena. "This is by far the hardest day," Tina says, admitting that she can't say if she's capable of giving 100 percent. "What I've decided is I'm just gonna play today and I'll make that decision in the moment," she says. It's that task where you have to make a pole and then use that pole to collect three keys on rings and unlock a door. The task begins and Tina starts coaching Katie immediately. Laura gets the first key. Laura gets her second as Katie gets her first. And then her third. Laura is a Redemption Island powerhouse and wins another Duel, leaving mother and daughter struggling. "The question is: Will Tina fight hard enough to defeat her daughter?" Probst inquires. Neither Katie nor Tina seems to have a particular desire to win. Tina, playing from behind, gets her third key. "Katie, are you OK with this?" Tina asks as she unlocks the first lock. "Are you sure?" she says after the second. "I love you. Sorry," Tina says, walking through her door and surviving. They cry. They hug. Tina explains that because she was adopted, she never felt a connection in life until she had Katie. Sniffle. "I'm so incredibly proud of both myself and my mother," Katie says. Sniffle. I suspect that recent events in their actual life made that hit me harder than it might have otherwise. Laura gives her daughter the clue to The Idol That Isn't There, while Tina tells Hayden to win the next challenge.
How do I trust thee? Let me count the ways. Hayden and Ciera have a more informative clue now to The Idol That Isn't There. Their strategy relies on winning Immunity and finding The Idol That Isn't There. As the music gets wicked dramatic, they climb trees and search. Monica strolls by, as you do. Hayden is convinced that he's isolated the right tree and since The Idol That Isn't There isn't there, he's sure Tyson has it. Back at camp, Gervase and Tyson are being friendly with Monica, keeping her content and happy. "1 to 10, how much do you trust me?" Gervase asks Monica. "10," she replies. Tyson gets the same score, while Ciera gets a "5." Monica is grateful that Tyson drew rocks rather than flipping on her, calling it a selfless act. She figures she'll have a lifelong bond, but she announces that she's playing the game for Monica. In the shelter, Ciera and Hayden decide their only play is to try to manipulate Monica, lying to her about things Tyson and Gervase have been saying.
In which a Jeff Probst cliche finally becomes relevant. Immunity is back up for grabs. The task involves swimming and some puzzle-solving. They're also playing for Reward. Want to know what they're playing for? A "Survivor" takeout menu. The first half of the challenge is entirely physical, so Hayden and Tyson have a big lead. As always, it'll come down to the puzzle component, in this case a familiar "Survivor" phrase. Really, everybody but Ciera gets to the puzzle at roughly the same time. It's an eight-word phrase and everybody is initially stumped. Probst keeps repeating over and over and over that it's a phrase he's said to them. Wow. From nowhere, Ciera spells, "You are going to have to dig deep." Ciera wins Immunity and skips to Jeff to get her necklace. Ciera gets to choose a lunch companion and, of course, it's Hayden.
That pizza didn't even look good. Ciera is ever-so-happy. "Oh my gosh! I just won!" Ciera says, all smiles. She can't wait to tell her mom, which is cute. She thinks she just proved that she didn't make a mistake in flipping on Tyson. "Now that I know what it feels like, I'm gonna be going for that every single time," she says. Hayden's happy to be "crushing" some food, but the majority alliance agrees that they're still planning on voting Hayden. Full of food, Ciera is ready to go after Monica, The Crack. At the beach, Ciera unloads to Monica, explaining that Tyson is a villain and that he was talking "mad crap" about Monica. She spins an elaborate lie about the things Tyson has said about her, all things Tyson probably *has* said about Monica, but not in the context Ciera's explaining. Monica has some faith in Tyson after the rock-drawing, but the only thing easier than shaking Monica's faith is... Nothing, actually. Shaking Monica's faith is the easiest thing in the world. And she's shaken. But will she be stirred to action? Monica says "It's now become a Me game," Monica says, vowing to go on offense. Tyson is worried, but Gervase is confident.
Tribal Council. "Katie looks hot," Hayden says, checking out the new Jury member with clean hair. Even Ciera is impressed. Probst steers conversation to Hayden and Ciera being on the outs. Scrambling, they go after Monica, chipping away, even as Tyson tries to protest. Gervase declares, "One man's perception is another man's reality. Why they perceive is a reality to them." Monica explains what Ciera told her and says that "perhaps" there is truth. Tyson says that Ciera lies as well, but Ciera protests that her conversation with Monica was woman-to-woman. Ciera plays this HARD. "It's funny how they're telling Monica this now, when they're desperate to stay in the game," Gervase says smartly. Hayden and Gervase get into a heated fight about who's controlling each alliance. Ciera keeps pushing on the "Evil, rude things" Tyson has said. Monica is digging deep and vows that a new side of her has come out. "Morality and ethical issues are going to bite you in the ass in the end," Monica says and Gervase squirms. I like the way Ciera and Hayden have decided that "dog" is the word that gets Monica's goat. Ciera's going over-the-top here, talking about Monica's family cheering her big move. If she were trying to convince any fully rational person this wouldn't work, but she knows what'll work with Monica. I don't think she's wrong.
The Vote. Probst goes to tally. Nobody plays an Idol. Probst tallies: Hayden. Gervase. Hayden. Gervase. HAYDEN. Monica stuck with her alliance. Hayden is gracious and smiley.
Bottom Line, Part I. I'd be hard-press to say that what Katie played was "a good game," but I think it was a pretty solid floating game when you consider that, by rights, she should have been the first person voted out of the game. She was the weakest player at that first challenge and in many or most seasons, she just gets sent packing without hesitation. Instead, she ducked and dodged and was amenable with anybody who would keep her around and people kept getting voted out before her. She wasn't playing a game that, under any circumstances, could have won, but I'll give her full credit: She could have lasted one day and she lasted 33. That's a decent run.
Bottom Line, Part II. And while I'm giving kudos, kudos to Ciera and Hayden for the scrambling effort they put in these past couple weeks. Well, maybe not kudos to Ciera, who still upset the applecart last week and, at least as of now, hasn't put herself in better position to win. If she was No. 4 in the Monica/Tyson/Gervase alliance, she's No. 4 outside of it as well. Lots of pieces were moved around and nothing changed, except that her chances of moving up to three seemed better from inside the alliance than from outside. We assume that one more person is coming back into the game, but I don't see how anybody from Redemption would shake things up, but that's only because we didn't get any comparative sense of Monica's relationship with Laura or Tina. But Hayden and Ciera created drama the past two weeks while accomplishing nothing and "Survivor" requires drama, however hollow.
Bottom Line, Part III. I feel like we still have too many people left. There are seven people still technically alive in the game and there's zero chance I'm doing seven exit interviews next Monday morning. Probably I'll end up saying that I want to talk to the Top 3 plus, if they don't make the Top 3, Tyson and/or Gervase. I probably want to talk to those guys no matter what. This hasn't been a season with only one dominant figure. Brad Culpepper was the most visible figure for 14 days. Aras and Vytas were the most visible figures for at least another week. And Tyson and Gervase have been in control ever since. Nobody beats Tyson in the Final 3. Probably if Tyson goes out before then and Gervase is still there, nobody beats him. But what are the various permutations in a game in which something shocking happens and the next two players out are Tyson and Gervase, leaving a Final Three of Ciera, Monica and Redemption Returnee TBD. Tina beats nobody. I may not be sure of anything else, but I'm sure of that.
Thoughts on tonight's episode and the season heading towards Sunday's finale?


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Background and Purpose. Pelvic-floor muscle (PFM) exercises are effective in reducing stress urinary incontinence (SUI), but few studies have investigated the effect of specific exercise variables on treatment outcomes. This study explored the effect of exercise position on treatment outcomes in women with SUI. Subjects and Methods. Forty-four women were randomly assigned to exercise in the supine position only or in both supine and upright positions. Bladder diary, pad test, urodynamic test, quality-of-life (Incontinence Impact Questionnaire [IIQ]), and PFM strength outcomes were obtained at baseline and after treatment. Results. Exercise position did not affect outcomes. After data from both groups were collapsed, statistically significant improvements with treatment were observed in bladder diary, IIQ, PFM strength, and urodynamic test results. Discussion and Conclusion. Exercise position did not differentially affect treatment outcomes. However, women in this study achieved a mean 67.9% reduction in the frequency of SUI episodes and improvements in other study outcomes. [Borello-France DF, Zyczynski HM, Downey PA, et al. Effect of pelvic-floor muscle exercise position on continence and quality-of-life outcomes in women with stress urinary incontinence. Phys Ther. 2006;86:974–986.]
Stress urinary incontinence (SUI) is the involuntary loss of urine that occurs with physical exertion and a rise in abdominal pressure.1 Coughing, sneezing, straining, jumping, and running are events commonly associated with SUI. Mechanisms underlying the development of SUI include pudendal nerve injury during vaginal delivery,2 incomplete pudendal nerve regeneration after delivery,3 and loss of muscular, ligamentous, and fascial support of the urethra and bladder.4 Symptoms of SUI occur when the anatomic and functional integrity of the urethral sphincter complex cannot resist forces associated with increases in intra-abdominal pressure. Because the levator ani muscles contribute to continence by providing support to pelvic organs and by enhancing urethral closure,5,6 pelvic-floor muscle (PFM) exercises have been recommended in the initial conservative management of SUI.7
Since the introduction of Kegel exercises in 1948,8 the efficacy of PFM exercises in the treatment of SUI and mixed urinary incontinence (symptoms of stress incontinence and urge incontinence) has been supported by the findings of several randomized controlled studies and systematic reviews.9–14 Compared with 3% cure and 15% improved continence rates for controls, Burns et al9 reported that 16% of women receiving PFM exercise training were cured and that 44% reported 50% to 99% improvement in symptoms. In a study carried out by Bo et al,10 56% of women who received PFM exercise training perceived their condition as "unproblematic" after treatment compared with only 3% of controls. Henalla et al11 reported that 65% of women who received PFM exercise training had at least a 50% reduction in urine loss on a pad test compared with no reduction in urine loss for the control group. Using biofeedback-assisted PFM exercise training and self-monitoring with bladder diaries, Goode et al12 found that women with predominant SUI symptoms showed a mean 68.6% reduction in the frequency of incontinence episodes compared with a mean 52.5% reduction in incontinence episodes for controls, who were given comprehensive written instructions in the form of an 8-week self-help behavioral program. Differences in outcome measures and rehabilitation methods, including the use of biofeedback, the number of muscle contractions performed per day, and specific muscle contraction variables (eg, contraction duration and emphasis on endurance versus strength training), may account for differences in reported success or improvement rates.9–12 Thus, although PFM exercises have been accepted as an effective intervention for SUI, many questions regarding exercise guidelines are not yet answered.
Evidence to guide PFM rehabilitation from both exercise physiology and functional perspectives is needed. The amount and timing of PFM force may be task dependent. Pelvic-floor muscle exercises often are taught and practiced with the participant in a relaxed, supine position. Whether or not the benefits of training gained in this context are adaptable to muscle strength (force-generating capacity) and coordination demands associated with more functional contexts is unknown. However, the findings of a recent study aimed at identifying differences in PFM strength measurements obtained in supine and standing positions suggest that muscle demands may be influenced by position. Using a vaginal balloon catheter connected to a pressure transducer, Bo and Finckenhagen15 observed that the mean resting vaginal pressure was 8.6 cm of H2O higher when recorded with women standing than when recorded with women lying supine. No differences were observed in the subjects' abilities to produce maximum squeeze pressure or maximum contraction duration when the 2 postures were compared. The higher resting pressure recorded during standing suggests that vaginal pressure may be influenced by gravity.15
If muscle activity demands are influenced by body position, then a PFM exercise program performed in a gravity-eliminated position may be less effective than one performed in upright positions. The aim of the current investigation was to compare the efficacy of a PFM exercise progression that included practice in upright positions (supine, sitting, and standing) with the efficacy of one that included practice in the supine position only in reducing female SUI. We hypothesized that women who exercised in both the supine and upright positions would have better urinary, strength, and quality-of-life outcomes than would women who exercised in the supine position only.
Subject Recruitment and Screening
Recruitment sources included local newspaper advertisements, the Magee-Womens Research Institute Web site, and physician referrals from the Department of Obstetrics, Gynecology, and Reproductive Science at the University of Pittsburgh at Magee-Womens Hospital. Potential subjects were screened by telephone (by CR or DBF) or in person (by CR) after signing the Magee-Womens Hospital Research Registry for Women and Infant's Health) to determine eligibility for examination. To be eligible, women had to be 38 to 70 years of age, not pregnant, and ambulatory. They also had to describe symptoms of SUI occurring at least once a week, and they had to deny symptoms of urgency or urge urinary incontinence (UUI). To screen for SUI symptoms, women were asked whether they leaked urine when they coughed, sneezed, laughed, or exercised or with physical exertion, such as lifting something heavy or moving furniture. To screen for UUI symptoms, women were asked whether they believed they emptied their bladder too often, whether they frequently experienced a sudden desire to urinate that could not be stopped, whether urine leakage occurred with a sudden and strong desire to urinate that could not be stopped, or whether they experienced urine leakage on the way to the bathroom. Women were considered ineligible if they indicated prior treatments for SUI (collagen injection, medications affecting bladder tone, pessary, or surgery). In addition, they were considered ineligible if they had been taught how to contract their PFMs and had been prescribed a PFM exercise program by a physician, nurse, physical therapist, or other health care professional. Additional exclusion criteria included having a pacemaker, using an intrauterine device, or having a medical history of pelvic cancer, severe endometriosis, or neurologic or metabolic disorders likely to impair bladder or sphincter function. Eligible subjects were sent a baseline bladder diary and were scheduled for a clinical examination.
Pretreatment Examination
Subjects provided informed consent before initiation of the clinical examination. A nurse practitioner and a physical therapist examined all subjects. The clinical examination consisted of a medical history and bladder diary review, physical examination, and urodynamic evaluation.
The nurse practitioner performed all urodynamic evaluations. Urodynamic evaluations with external water pressure transducers were performed with an EKO Urodynamics System,* a no. 7 French double-lumen urethral catheter,† and a rectal balloon catheter‡ to measure intra-abdominal pressure. Postvoid residual urine was removed through the urodynamic catheter before bladder filling. Transducers were zeroed to each subject. Postvoid residual urine was documented by catheterization within 15 minutes of voiding. The bladder was retrograde filled with room temperature sterile water at a continuous rate of 50 mL/min. Bladder filling stopped when the subject reported a strong urge to urinate, indicating maximum cystometric capacity. Any evidence of detrusor instability was recorded. Once maximum cystometric capacity was reached, the bladder catheter was removed and provocative stress maneuvers (Valsalva followed by cough) were performed. Provocative maneuvers were done first with the subject in the lithotomy position. If leakage did not occur, then provocative maneuvers were repeated in the standing position.
Clinical examination and urodynamic evaluation results determined continued study participation. Subjects were excluded from further participation if they recorded UUI episodes or less than one SUI episode on the 7-day baseline bladder diary. Likewise, they were excluded if they had vaginal wall prolapse beyond the vaginal introitus, an inability to demonstrate a palpable PFM contraction, sensory loss below the L4 dermatome, atrophic vaginitis or skin breakdown around the perineum (preventing the use of a vaginal electromyographic [EMG] sensor), lumbosacral or pelvic pain or dysfunction that would interfere with PFM exercises, or the inability to tolerate the supine position. Exclusion on the basis of urodynamic findings occurred if a woman demonstrated detrusor instability or an abdominal leak point pressure of less than 60 cm of H2O. The urodynamic criteria minimized the chance that women with intrinsic sphincter deficiency or UUI would be included in the study.
Study Outcome Measures
Study outcome measures were obtained at the baseline and posttreatment examinations. Outcomes included frequency of incontinence episodes recorded on the bladder diary, urine leakage demonstrated during urodynamic testing, amount of urine leakage determined from a pad test, quality of life, and PFM strength.
Bladder diary.
Subjects were provided a 1-week bladder diary before the baseline examination, at each physical therapy visit, and 1 week before the posttreatment examination. The 1-week bladder diary has been shown to have high test-retest reliability for diurnal and nocturnal micturition frequency and the number of incontinence episodes (r=.86–.91).16 Subjects recorded the time of each void and incontinence episode and the circumstances of each incontinence episode (eg, urgency, cough, or sneeze).
At baseline, average voiding frequency per day, the number of incontinence episodes per week, and the circumstances of each incontinence episode were extracted from the diary. Voiding frequency and the circumstances of each incontinence episode were reviewed to rule out the presence of urgency and UUI.
The number and circumstances of incontinence episodes were extracted from the bladder diary at the beginning of each physical therapy visit. This information was used by the physical therapist to guide exercise progression, to motivate the subject, and to educate the subject on strategies to prevent future SUI episodes. Data from the baseline and posttreatment diaries were used to determine pretreatment-to-posttreatment changes in the frequency of incontinence episodes.
Urine leakage during urodynamic testing.
Urodynamic testing was performed at the baseline and posttreatment examinations by use of the procedure described earlier. Evidence of SUI and the coincident leak point pressure were recorded.
Amount of urine leakage.
A modification of the 1-hour pad test recommended by the International Continence Society17 was used to quantify the amount of urine leakage. We chose this particular test because of its brevity and because it has been shown to have high test-retest reliability in women with SUI.18
We administered the pad test at the baseline and posttreatment examinations immediately after urodynamic testing. We assumed that, in the absence of detrusor instability, urine loss would be minimal and the subject's bladder still would be full. At the time of testing, the subjects were not menstruating, and any lubricant used for urodynamic testing was removed. A preweighed Depend Undergarment§ was worn by subjects to collect urine lost during the test. An Ohaus model CR 1200 Portable Advanced Scale‖ was used to weigh the undergarment. The scale was calibrated before weighing of any pad. After subjects donned the pad, they were asked to walk 45 m (50 yd) at a comfortable pace. Subsequently, they performed the following provocative maneuvers 5 times: climbing a step, coughing, heel bouncing, and standing up from a sitting position. Finally, subjects placed their hands under running water for 1 minute. The undergarment was removed and weighed to determine urine loss.
Quality of life.
Quality of life was measured with the Incontinence Impact Questionnaire (IIQ).19 The IIQ is a 30-item questionnaire designed to assess the effect of urinary incontinence across 4 domains: physical activity, travel, social relationships, and emotional health. The internal consistency, reproducibility, construct validity, and sensitivity of the IIQ were established for a population of community-dwelling women with SUI or UUI.19 Subjects completed the IIQ at the baseline and posttreatment examinations. Scores on the IIQ range from 0 to 400, with a higher score indicating poorer perceived quality of life.19
PFM strength.
Pelvic-floor muscle strength was examined through digital assessment and quantified by the method of Brink et al.20 The Brink scale considers 3 muscle function dimensions: muscle contraction duration, squeeze pressure felt around the examiner's fingers, and vertical displacement of the examiner's fingers as the PFMs contract. Each variable is rated separately on a 4-point categorical scale. The 3 subscale scores are summed to obtain a composite score ranging from 3 to 12. The interrater reliability, test-retest reliability, and validity of this strength assessment have been reported.20,21 Pelvic-floor muscle strength was assessed during the baseline and posttreatment examinations.
A recent review from the Cochrane Database of 22 studies examining the use of PFM exercises as an intervention for SUI concluded that studies are unclear and inconsistent with regard to PFM exercise variables, including whether or not daily practice is expected, the prescribed muscle contraction duration, and the number of muscle contractions prescribed per day.14 When evidence was found to support a particular PFM exercise variable, we integrated the evidence into the design of our intervention protocol. However, with regard to exercise progression, there was a lack of literature upon which to base our intervention protocol. Therefore, we devised an intervention protocol that could be individualized for each participant by progressing exercises with considerations for preventing muscle fatigue and enhancing exercise adherence.
The reviewed studies reported the most common PFM intervention length to be 12 weeks.14 To enhance the comparison of our results with those of other studies, we also selected a 12-week maximum intervention length. However, Dougherty et al22 showed that women with SUI made the greatest improvements in both urine loss and muscle strength outcomes in the first 8 weeks of a 16-week PFM exercise intervention. On the basis of these findings, we implemented a 9- to 12-week intervention length with sessions conducted at 1-week intervals. A physical therapist determined the maximum number of visits based on an evaluation of subjects' bladder diaries. If subjects were continent (no episodes of urine loss recorded on the bladder diaries) for 2 consecutive weeks by session 9, then they were scheduled for the postintervention examination. Otherwise, subjects received 1 to 3 more visits until they recorded continence on the bladder diaries for 2 consecutive weeks, showed a stable maximum reduction (no further reduction or increase for 3 weeks) in incontinence episodes, or completed the 12-week intervention. Implementing a 9- to 12-week intervention length minimized subject burden for those who achieved continence earlier on while allowing others further opportunity to benefit from the study protocol.
During each visit, a Pathway Dual-Channel Surface Biofeedback System# interfaced with Synergy Plus Software# was used to provide subjects with EMG feedback. A single-user, Perry/Pathway Vaginal EMG Sensor# was used to record PFM activity. A disposable pregelled surface electrode was placed medial or lateral to the left anterior superior iliac crest to monitor accessory abdominal muscle activity. Synergy Plus Software provided both visual and auditory cues that signaled subjects to initiate muscle contraction and relaxation. Subjects also were able to view their PFM activity and abdominal muscle activity on the computer screen. The EMG data were used by the therapist to guide and individualize exercise prescription.
The first intervention visit occurred immediately after the clinical examination. Using EMG biofeedback, subjects were instructed by the therapist to perform a 3-second maximum PFM contraction. The purpose of practicing a short-duration maximum contraction was to promote the ability to initiate a muscle contraction with maximum force and speed. It has been suggested that the PFMs contract during a cough as part of a preprogrammed sequence of muscle activation that also includes the intercostal, abdominal, diaphragmatic, and sphincter muscles. In addition, the PFMs assist continence through a properly timed voluntary contraction coincident with the contraction of urethral sphincter muscles to support the vesical neck and occlude the urethral lumen.23 Therefore, the ability to quickly produce a strong muscle contraction is of functional importance in preventing urine leakage during a sudden rise in abdominal pressure, such as during a cough or sneeze.24,25
For the 3-second maximum contraction, the therapist instructed subjects to "contract your PFMs as quickly and as hard as you can; try to hold the contraction for the entire 3 seconds." When accessory muscle activity from the gluteal or hip adductor muscles was observed, the therapist instructed the subjects to relax these muscles. Instruction to reduce abdominal muscle activity was given only if the subjects strained, causing the abdominal sensor to dislodge, or if abdominal muscle activity predominated over PFM activity. During this session, subjects performed 20 repetitions of the 3-second contraction over a 3-minute interval. A 6-second rest interval followed each muscle contraction. Depending on fatigue, subjects performed 1 or 2 additional trial blocks (20 repetitions each) of the 3-second contraction. A 2- to 3-minute rest interval was provided between each block of contractions. We defined fatigue as a reduction in the subjects' peak EMG over 3 consecutive contractions to below 50% of the average peak EMG demonstrated during the first practice block of 20 contractions. At the end of this visit, the therapist provided subjects with a home exercise program. The therapist also educated subjects with regard to PFM anatomy and physiology. The maximum exercise prescription at this visit was 20 repetitions (2 sets of 10) of the 3-second contraction provided the subjects did not demonstrate fatigue during practice. Otherwise, the number of repetitions prescribed equaled the average number of contractions the subjects performed in trial blocks 1 to 3. Subjects were instructed to perform their home exercise program twice a day.
At the second intervention visit, the therapist inquired about the subjects' ability to perform the home exercise program and reviewed the bladder diaries to enhance subjects' awareness of any changes in their SUI episodes over the preceding week and to help them understand the precipitants of SUI. Using EMG biofeedback, subjects' performance of the 3-second maximum contraction (with the same procedure as that outlined for intervention visit 1) was reevaluated. In addition, subjects were instructed to perform a 12-second PFM contraction. Constant tonic PFM activity contributes to pelvic organ support and prevents strain on pelvic ligaments and fasciae.26,27 Therefore, we included practice of a longer-duration contraction to promote PFM endurance capacity.25
For the 12-second contraction, subjects were instructed to "contract your PFMs as hard as you can but focus on keeping the contraction as steady as you can for the 12 seconds." The procedure for providing feedback to subjects regarding accessory muscle activity was the same as that outlined for intervention visit 1. Subjects practiced 10 repetitions of the 12-second contraction. A 24-second rest interval followed each muscle contraction. Depending on fatigue (as defined previously), subjects performed 1 or 2 additional trial blocks (10 repetitions each) of the 12-second contraction. A 2- to 3-minute rest interval was provided between each block of contractions. Then, the therapist revised the subjects' home exercise program to include practice of the 3-second and 12-second contractions. The maximum exercise prescription at this visit was 20 repetitions (2 sets of 10) of the 3-second contraction and 10 repetitions (1 set) of the 12-second contraction provided the subjects did not demonstrate fatigue during practice. Otherwise, the number of repetitions prescribed per set equaled the average number of contractions the subjects performed in trial blocks 1 to 3 for each contraction type. Subjects again were instructed to perform their home exercise program twice a day. Exercise progression at this and all subsequent visits also depended on the subjects' successful performance of the previous home exercise program. In addition, if a subject identified a barrier to exercise, then the therapist provided recommendations to minimize exercise barriers. For example, if a subject could not remember to exercise, then the therapist recommended linking exercise to another well-established behavior, such as brushing teeth or watching the evening news.
Like visit 2, the third intervention visit began with the therapist reviewing and discussing with subjects their bladder diaries, their home exercise program performance, and any exercise barriers they experienced. The subjects' ability to perform the 3-second and 12-second contractions was reevaluated with the same procedures as those described for visit 2. At this session, subjects were randomized to either the supine or the combined supine-upright exercise progression. A block randomization schedule was determined with a random-number table. Five blocks with 10 assignments were created, with equal representation of both groups. Random assignment followed the block schedule, with the exception of balancing groups with regard to age (within 5 years) and incontinence severity (determined from the baseline bladder diary: minimal=<5 episodes per week, moderate=5–10 episodes per week, and severe=10 episodes per week). Subjects assigned to the supine group were advised to continue their exercises in the supine position. Subjects assigned to the combined supine-upright group were instructed to perform 1 set of each exercise (3- and 12-second contractions) in the supine, sitting, and standing positions. The maximum exercise prescription at this visit was 20 repetitions (2 sets of 10) of the 3-second contraction and 20 repetitions (2 sets of 10) of the 12-second contraction provided the subjects did not demonstrate fatigue during practice. Otherwise, the number of repetitions prescribed per set equaled the average number of contractions the subjects performed in trial blocks 1 to 3 for each contraction type. Subjects were instructed to perform their home exercise program twice a day. At this visit, the therapist instructed subjects to use the "stress strategy,"28,29 that is, to contract their PFMs in anticipation of or during a cough or sneeze or any other activity that usually led to leakage. The therapist reinforced the use of the stress strategy at each subsequent visit during the bladder diary review.
Reexamination and exercise progression at visits 4 to 12 followed the same procedures as those outlined for visit 3. The maximum exercise prescription at visit 4 was 30 repetitions (3 sets of 10) of the 3-second contraction and 30 repetitions (3 sets of 10) of the 12-second contraction performed twice daily. Otherwise, the number of repetitions prescribed per set equaled the average number of contractions the subjects performed in trial blocks 1 to 3 for each contraction type. Subjects in the supine group performed all exercises in the supine position, whereas subjects assigned to the combined supine-upright group performed 1 set of exercises for each contraction type (3 seconds and 12 seconds) in the supine, sitting, and standing positions. From visits 5 to 12, the home exercise program continued to be progressed on the basis of the number of contractions performed in trial blocks 1 to 3 before the onset of fatigue for each contraction type. The maximum exercise prescription possible by visit 12 was 60 repetitions (3 sets of 20) of the 3-second contraction and 30 repetitions (3 sets of 10) of the 12-second contraction performed twice daily.
Posttreatment Examination
At the last intervention visit, subjects were given a posttreatment bladder diary to complete for 7 days before the posttreatment examination. The reexamination was scheduled within a 2-week period after the final intervention visit. During the reexamination, measurements for all study outcomes were obtained.
Data Analysis
To determine any baseline differences in age, number of urine leaks per week, and amount of urine loss on the pad test, groups were compared by use of independent t tests. Mann-Whitney U tests were performed to determine baseline group differences in IIQ and Brink scores. Baseline group differences in the proportion of women in each exercise group who experienced urine leakage during urodynamic testing were analyzed by use of chi-square analysis.
The effect of exercise position on intervention outcomes was determined by analyzing differences between preintervention and postintervention scores for bladder diary, pad test, quality-of-life, and PFM strength outcomes. This study applied an intention-to-treat analysis. Therefore, when a subject did not complete the study, her most recent bladder diary was used to calculate the preintervention-to-postintervention change in the number of urine leaks per week. Because pad test, quality-of-life, and PFM strength data were obtained only at baseline and postintervention evaluations, a zero change in values for these outcomes was entered for subjects not completing the study. Any group differences identified for baseline measures as statistically different or clinically important were adjusted for in the appropriate preintervention-to-postintervention outcome analyses.
A one-way analysis of variance was used to detect differences between the 2 groups in preintervention-to-postintervention reductions in the number of urine leaks per week and the amount of urine loss on the pad test. A Kruskal-Wallis one-way analysis of variance by ranks was used to detect group differences in preintervention-to-postintervention changes in IIQ and Brink scores. Postintervention exercise group differences in the proportion of women who demonstrated urine leakage during urodynamic testing were determined by use of chi-square analysis. The number of visits attended and the number of prescribed 3-second and 12-second contractions for both groups were compared by use of independent t tests.
When group assignment did not affect intervention outcomes, data from both groups were collapsed for further analysis. Baseline-to-postintervention changes in the number of urine leaks per week and the amount of urine loss on the pad test were analyzed by use of paired t tests. Baseline-to-postintervention changes in IIQ and Brink scores were analyzed by use of the Wilcoxon signed rank test. The McNemar test was used to test baseline-to-postintervention changes in the distribution of women who did and women who did not have urine leakage during urodynamic testing.
To summarize the effectiveness of PFM exercises in improving continence, a percentage of reduction in incontinence episodes determined from the pretreatment and posttreatment bladder diaries was calculated for each subject with the following formula: [(pretreatment –posttreatment number of incontinence episodes)/pretreatment number of incontinence episodes] × 100. In addition, the percentages of reduction in scores were averaged to obtain an overall percentage of reduction in incontinence episodes for the entire sample of women.
Eighty women were screened for study eligibility. Forty-six women were eligible for participation; however, at the pretreatment examination, 1 woman demonstrated detrusor instability during urodynamic testing and another woman recorded episodes of UUI on her baseline bladder diary. Therefore, only 44 women continued into the study's intervention phase. The mean age of the 44 women was 52.6 years (SD=8.5 years). The median parity was 2, and 57% of the sample was postmenopausal. Forty-one women were white, 2 were African American, and 1 was Asian. Twenty-two women were randomly assigned to each treatment group.
Baseline measures for subjects in both groups are shown in Table 1. Before the intervention, there were no statistically significant differences between groups with respect to age, number of urine leaks per week, amount of urine loss on the pad test, IIQ scores, or Brink scores (all P values >.05). Although not statistically significant, there was a trend for a larger amount of baseline urine loss on the pad test for women assigned to the combined supine-upright exercise group. This result caused us to adjust for baseline urine loss on the pad test in subsequent preintervention-to-postintervention bladder diary and pad test analyses.
The percentage of women in each group who had urine leakage during urodynamic testing at baseline, demonstrating urodynamic stress urinary incontinence (USUI), also is shown in Table 1. Urodynamic stress urinary incontinence was diagnosed in 59% of the entire study cohort. There was no difference in the prevalence of USUI between the exercise groups at baseline.
Baseline-to-Postintervention Changes in Outcome Measures
Baseline-to-postintervention changes in bladder diary, pad test, quality-of-life, and PFM strength outcomes are shown by exercise group in Table 2. Reductions in the number of urine leaks per week and the amount of urine loss during the pad test were not statistically different between the exercise groups. Likewise, there were no statistically significant differences in improvements in IIQ or Brink scores. Table 2 also shows the prevalence of USUI postintervention by exercise group. The prevalence of USUI decreased to 41% for the entire study cohort. Exercise position did not have an impact on the prevalence of USUI postintervention between the exercise groups.
Five (22.7%) of the women assigned to the supine exercise group and 3 (13.6%) of the women assigned the combined supine-upright exercise group dropped out of the study. The number of visits attended did not differ by exercise group. Including data for dropouts, means for the number of visits attended were 8.4 (SD=2.8, range=2.0–12.0) and 8.9 (SD=3.0, range=1.0–12.0) for the supine and combined supine-upright exercise groups, respectively (P=.53). For those who completed the trial, means for the number of visits attended were 9.88 (SD=1.11, range=9.0–12.0) and 10.16 (SD=1.01, range=9.0–12.0) for the supine and combined supine-upright exercise groups, respectively (P=.42). The numbers of exercises prescribed by the therapist did not differ between the exercise groups. Means for the prescribed number of 3-second contractions were 75 (SD=32.5) and 81 (SD=32) for the supine and combined supine-upright exercise groups, respectively (P=.52). Means for the prescribed number of 12-second contractions were 50 (SD=16.3) and 50 (SD=14.7) for the supine and combined supine-upright exercise groups, respectively (P=.96).
Because exercise position did not affect intervention outcomes, we collapsed data from both groups for further analysis. The baseline-to-postintervention comparisons of the number of urine leaks per week, amount of urine loss on the pad test, IIQ scores, and Brink scores are shown in Table 3. This sample of women demonstrated a statistically significant reduction in the number of urine leaks per week, as reported on the bladder diary, from baseline to postintervention evaluations.
The amount of urine lost during the postintervention pad test decreased from that at baseline; however, this change did not reach statistical significance. Statistically significant improvements in IIQ and Brink scores were observed after intervention (Tab. 3). Table 3 also shows the prevalence of USUI for all women before and after intervention. We found a statistically significant reduction in USUI prevalence following intervention. The proportion of women who had urine leakage during this test decreased from 59% at baseline to 41% following intervention.
The percentage of reduction in incontinence episodes documented in the preintervention and postintervention bladder diaries for the entire group of women is shown in the Figure ⇓. Almost 41% of the women experienced 100% resolution of their SUI symptoms, whereas another 20.5% experienced at least a 75% reduction in their symptoms. Overall, the women in this study achieved a mean 67.9% reduction in the frequency of incontinence episodes as a result of treatment. For treatment efficacy purposes, the percentage of reduction in incontinence episodes also was examined for the 36 women who completed the trial. The mean reduction in the frequency of incontinence episodes for these women was 78.8%.
Our hypothesis that women who had SUI and who performed PFM exercises in both supine and upright positions would obtain better treatment outcomes than women who exercised in the supine position only was not supported. These results were surprising, as they appear to disagree with current training specificity theory, which suggests that greater gains in motor performance occur when practice most closely approximates task or functional requirements.30 In addition, they seem to be inconsistent with the results of studies related to enhancing muscle strength and performance, which do support training specificity theory. Experimental evidence has shown that improvements in muscle performance are specific to training velocity31,32 and muscle length or training angle.33 The importance of posture specificity in muscle training also has been shown.34,35 Exercise position did not affect outcomes in this study. This finding may be attributed to our focus on continence outcomes and not on specific muscle force and timing outcomes. In addition, we measured muscle strength by digital examination with the subject lying supine. Although the exercise groups achieved similar PFM strength gains, this finding should be interpreted within the limitations imposed by the testing method and position.
Our findings suggest that other exercise variables may be more critical than position in enhancing urinary continence outcomes. For instance, contraction duration, rate of force production, or the number of contractions prescribed may be of equal or greater importance. The exercise protocol used in this study applied the concept of muscle loading by increasing the number of muscle contractions performed. The number of prescribed muscle contractions in our protocol was higher than that reported in other studies.10,12 Although the numbers of contractions performed by women in our study did not differ between exercise groups, it is plausible that the high contraction repetition provided a mechanism for increasing muscle function that was not enhanced further by changing exercise position.
In addition, it is possible that women did not adhere to their assigned exercise position, diluting group outcome differences. We did not formally track participants' adherence to the assigned exercise position. However, at each study visit, we reinforced with women the importance of exercising only in their assigned position. Reasons can be hypothesized for why either group may have deviated from the assigned protocol. Women assigned to the supine-only exercise group may have exercised in the upright position for the sake of convenience. Women assigned to the combined supine-upright exercise group may have exercised in the supine position because they believed it was less fatiguing. Therefore, we believe that if nonadherence occurred, it did so with similar frequencies across groups, thus not biasing outcomes.
The focus of our treatment protocol was not limited to enhancing PFM strength and endurance. Women in our study were taught to use the stress strategy28,29 to prevent urine leakage by contracting their PFMs in anticipation of a cough, sneeze, or other activity that precipitated a SUI incident. This skill depends not only on muscle strength but also on the ability to anticipate the SUI event and properly time the muscle contraction. From a functional perspective, practice of voluntary PFM contractions to occlude the urethra and prevent urine loss is critical. Therefore, we made the decision to teach both groups of women to use the stress strategy to prevent urine loss. As a result, some opportunity to exercise in upright positions was afforded to the group of women assigned to exercise in the supine position. We cannot dispute the possibility that this opportunity may have reduced our chances of finding different outcomes for women assigned to the 2 exercise groups. Regardless, women in the combined supine-upright exercise group had significantly greater practice using their muscles in upright positions than did women in the supine-only exercise group. Therefore, if exercise position was a critical exercise variable, we believe that group differences in continence outcomes should have been observed.
From a task difficulty standpoint, PFM exercises in upright positions should be more difficult to perform than exercises in the supine position, as forces acting on the PFMs increase. Recently, Morgan et al36 found that bladder pressure at rest and during maximum voluntary PFM contraction was greater when continent women were standing than when they were lying down. In addition, they observed that most women could not contract their PFMs in a standing position without a concomitant increase in intra-abdominal pressure.36 In our study, several women indicated that they had greater difficulty knowing whether they were exercising correctly in the standing position. Likewise, many women indicated that exercises performed in the standing position were more fatiguing than those performed in the supine or sitting position. A woman who is unsure whether she is exercising correctly or is experiencing exercise-associated fatigue may be less likely to adhere to her exercise regimen. In this context, our findings are clinically significant because they allow a clinician greater flexibility in exercise prescription. On the basis of our data, a decision to have such a woman continue her exercise progression in the supine position should not compromise her continence outcomes.
Limitations in our study design may have lessened our ability to find differences between exercise interventions (supine only versus combined supine-upright). Most of the clinical outcomes were collected by the treating therapist. Only the urodynamic data were obtained by a clinician unaware of the assigned intervention group: the nurse practitioner. We believe that the threat of therapist bias was greatest for PFM strength outcomes, as it required the physical therapist to evaluate examination findings when assigning the Brink score. The statistical power to detect a difference in the reduction of urine leaks per week between women who exercised in the supine position only and women who exercised in the combined supine-upright positions was low (18%) and also should be considered a possible limitation in interpreting the results of this analysis.
Our results add to the body of evidence that supports the use of PFM exercises as an effective intervention for women with SUI. About 41% of the women in our study experienced a 100% reduction and 20.5% experienced at least a 75% reduction in the number of SUI episodes per week. The intention-to-treat analysis revealed that women who participated in our study achieved a mean 67.9% reduction in the frequency of SUI episodes. An even greater reduction in symptoms, a mean 78.8% reduction, occurred in women who completed the trial.
Differences in exercise protocol and study outcome measures impose some limitations on direct comparisons of our results with the results of other studies. However, our results are most similar to those reported by Goode et al.12 Their intention-to-treat and efficacy results revealed 68.6% and 80.2% reductions in incontinence episodes reported on bladder diaries for women with predominant SUI symptoms, respectively. In addition, women in both studies obtained statistically significant improvements in quality of life after treatment, as measured by the IIQ. The studies differ, however, in the percentages of women who reported a 100% reduction in incontinence episodes. Goode et al12 reported that less than 20% achieved a 100% reduction in incontinence episodes; in contrast, 41% of the women in our study became continent.
Our results appear to be much better than those reported by Wyman et al37 for a subgroup of women who had SUI and who participated in a 12-week intervention program including biofeedback training. From baseline to posttreatment evaluations, women in the study of Wyman et al37 showed about a 43% reduction in the number of incontinence episodes per week (from 15.3±14.5 [X̅±SD] at baseline to 8.7±0 [X̅±SD] after treatment). Additional data presented by Wyman et al37 detailing the percentage of reduction in incontinence episodes achieved posttreatment included women with SUI only and women with detrusor instability (with or without concomitant SUI). Thirteen percent of subjects achieved a 100% reduction in incontinence episodes, an equal number reported a 75% to 99% reduction, and 31% experienced a 50% to 74% reduction in incontinence episodes following treatment. Our cure and improvement rates also were higher than the 16% cure rate and the 44% improvement rate (50%–99% reduction in urine loss per week) reported by Burns et al.9 On the basis of a self assessment of their perceived condition, 56% of women treated with PFM exercises in a study by Bo et al10 indicated that their SUI was "unproblematic" following treatment. If "unproblematic" meant "continent," then our cure rate would be lower than that reported by Bo et al.10 However, an additional self-assessment of cure or improvement in SUI symptoms showed that 8%, 40%, and 44% of the women indicated that they were continent, almost continent, and improved, respectively.10
We hypothesize that the higher cure rate obtained in our study than in other studies9,10,12,37 may be attributed to differences in subject characteristics and exercise prescription. The studies by Burns et al,9 Goode et al,12 and Wyman et al37 included women with more severe SUI at baseline (the mean number of incontinence episodes per week ranged from 15.1 to 18) than that of the women in our study. Given the difference in symptom severity, it is not surprising that a higher cure rate was obtained in our study. However, the baseline incontinence severity in the study of Bo et al10 was lower (2.0±1.8 [X̅±SD] incontinence episodes over a 3-day period) than that in our study.
Lower cure rates also may be expected from comparison studies that included women with mixed urinary incontinence.9,12,37 However, as in our study, subjects in the study of Bo et al10 were excluded if they had urinary incontinence other than genuine stress incontinence. Therefore, we believe that discussion of the similarities and differences between our exercise protocol and those of the comparison studies may provide additional insight into the observed outcome differences.
We do not believe that treatment duration differences played a significant role. With the exception of the 6-month intervention in the study of Bo et al,10 treatment durations were comparable, ranging from 8 to 12 weeks. Although the comparison studies used methods slightly different from those that we used, we believe that the regimens in the comparison studies also were designed with the purposes of improving PFM endurance capacity and ability to prevent urine leakage during a sudden rise in abdominal pressure. All of the comparison studies included practice of a long-duration PFM contraction (at least 8 seconds).9,10,12,37 In addition, Burns et al9 and Wyman et al37 also recommended that their subjects perform a fast (3-second) contraction, and Bo et al10 instructed their subjects to add 3 or 4 fast PFM contractions after each sustained contraction. Goode et al12 used a 10-second PFM contraction but also taught women the stress strategy, which provided their subjects an opportunity to practice quick, forceful contractions.
One difference in our exercise protocol, the larger number of PFM contractions prescribed, may have contributed partially to our higher cure rate. Goode et al12 instructed women to perform 15 PFM contractions 3 times per day. The maximum daily number of contractions performed by subjects in the study of Wyman et al37 was 50. Bo et al10 also prescribed far fewer contractions, 8 to 12 contractions 3 times per day. Our higher maximum exercise dose may have allowed for more opportunity to promote strength and endurance through continued progressive muscle loading. However, Burns et al exceeded our maximum exercise prescription, advising subjects to perform 200 PFM contractions per day.9 Therefore, we hypothesize that our method of individualizing exercise prescription also may have contributed to our higher cure rate. Although most of the trials stated or implied that exercise repetitions progressed to a maximum number,9,12,37 the criteria upon which exercise progression was based were less clearly defined. We used data from the biofeedback session regarding muscle fatigue and from the women regarding their ability to perform the home exercise program to guide exercise prescription. Increasing exercise intensity without regard to limits imposed by a patient's musculoskeletal system and lifestyle runs the risk of nonadherence. Until studies undertake the difficult task of determining the optimal PFM exercise intensity and method for exercise progression for SUI, we believe that an approach that considers a patient's muscle function and ability to successfully perform a home exercise program, along with adequate progressive muscle loading, may be most prudent.
Although the exercise protocol used in this study was found to be effective in reducing SUI, generalization of the results is limited. The majority of women in this study had mild to moderate SUI, no urgency symptoms or urge incontinence, and no previous SUI treatment. The number of leaks per week at baseline for the entire sample was 7.0±6.2 (X̅±SD). Our sample also demonstrated a baseline Brink score of 8.5±2.3 (X̅±SD), indicating a substantial ability to contract PFMs before treatment. Women with more severe incontinence, mixed incontinence, prior treatment failures, or weaker baseline PFM strength should not be expected to achieve comparable outcomes.
We believe that the women recruited into this study were highly motivated. The attrition rate for the entire sample of women was only 18.6%, and the majority of women who left the study did so early on (3.3±1.9 [X̅±SD] visits). The most common reason for attrition was the inability to attend visits because of work. We believe that the low attrition rate is remarkable given the subject burden associated with this study.
Women completing our intervention trial received 9.8±1.3 (X̅±SD) visits with the physical therapist. We recognize that the number of physical therapy visits reimbursed by third-party payers may be smaller. However, to completely test the efficacy of our protocol, we wanted women to have the opportunity to reach stable progress before their discharge. In addition, we aimed to reduce exercise barriers by monitoring the women on a weekly basis. Therefore, the 78.8% reduction in incontinence episodes achieved by women completing the protocol may not be generalizable to situations with fewer visits and less monitoring by a physical therapist.
With regard to prescription of PFM exercises for women with SUI, several exercise variables can be manipulated, including the number of contractions performed per day, the duration of muscle contraction, the muscle contraction/rest ratio, and the exercise position. On the basis of data from this study, exercise position does not affect continence outcomes in a cohort of women who also are taught a preemptive stress strategy. Women who performed PFM exercises in both the supine and the upright positions did not obtain better continence outcomes than did women who exercised in the supine position only. These findings allow a clinician to approach exercise prescription with greater flexibility.
Along with data from other studies, our data support the efficacy of using PFM exercises as an intervention for management of female SUI. Women who completed the trial achieved a mean 78.8% reduction in SUI episodes. In addition, PFM exercises resulted in gains in quality of life and PFM strength and a reduction in urine leakage during urodynamic testing.
Dr Borello-France and Dr Downey provided concept/idea/research design. Dr Borello-France and Dr Zyczynski provided writing, project management, fund procurement, and institutional liaisons. Dr Borello-France, Dr Downey, and Ms Rause provided data collection, and Dr Borello-France provided data analysis. Dr Zyczynski provided subjects and facilities/equipment. Dr Zyczynski, Dr Downey, and Dr Wister provided consultation (including review of manuscript before submission).
All study procedures were approved by the institutional review boards of Duquesne University, University of Pittsburgh, and Chatham College.
Partial data from this study were presented orally at the Combined Sections Meeting of the American Physical Therapy Association; February 23–27, 2005; New Orleans, La.
This work was funded by National Institutes of Health/National Institute on Aging grant R15AG15488 to Dr Borello-France.
↵* Laborie Medical Technologies, 310 Hurricane Ln, Williston, VT 05495.
↵† Cook Urological Inc, PO Box 227, 1100 W Morgan St, Spencer, IN 47460.
↵‡ Rusch Inc, 2917 Weck Dr, Durham, NC 27709.
↵§ Kimberly-Clark Worldwide Inc, Texas Commerce Tower Bldg, Irving, TX 75062.
↵‖ Ohaus Corp, PO Box 2033, 19A Chapin Rd, Pine Brook, NJ 07058.
↵# The Prometheus Group, One Washington St, Suite 303, Dover, NH 03820.
- Received June 14, 2005.
- Accepted February 7, 2006.
- Physical Therapy


text:
pages from black punk zine, Shotgun Seamstress by Osa Atoe (2006-2015)
pages from black punk zine, Shotgun Seamstress by Osa Atoe (2006-2015)
Shotgun Seamstress Zine Anthology will be available to order in late September, and can also be picked up at the POC Zine Project tour.
Shotgun Seamstress Zine Collection (six zines by & for Black punks) will include all the issues of Osa Atoe's zine, which includes a ton of interviews, reviews, and so much more! We are extremely proud to help put out this book, and we hope you are equally as excited to read it.
Cover of Issue 8 of Shotgun Seamstress by Osa Atoe - featuring interviews with and articles about black punk rockers, artists, musicians, queers and more
Every issue of Shotgun Seamstress (including the long out of print Issue #3 and the non-anthologized Issue #6.5) are back in stock!
osa, philadelphia, 2012
By Itoro Udofia, Legacy Series Intern
Itoro recently read all six issues of Shotgun Seamstress in a row. Here is what she learned from them:
It's hard to speak to everything the Shotgun Seamstress zine collection taught me. It really does give you everything: interviews, stories, being queer, black, punk, female, broke, weird, loving music, knowing your history, loving yourself…it draws from a lot of sources and that right there sums up this history of the punk scene and the Black experience: We pull from everywhere and we survive and thrive too.
That's my biggest lesson, but here are five more just for good measure:
1. WE need our people
Reading Shotgun Seamstress opened my eyes to our need for each other's affirmation, community and understanding while trying to do the impossible: live in the margins. It's important that when we find each other, we do what we can to build community and lift each other up, usually we're the only black face in the white crowd. Many of the punk rockers, artists, drag queens, musicians, made that clear in Shotgun Seamstress. From how white the punk scene is, specifically, and how black folks are constantly pushed to the margins, it's important for us, as Audre Lorde so eloquently puts it, "to practice how to be tender with one another." I was shocked and awed to see the type of love and gentleness Shotgun Seamstress had to the multiplicity of voices it brought in.
2. Our struggles affirm one another
THE WOMEN OF COLOR IN PUNK CONFERENCE organized by Osa Atoe was talked about in the zine series as an affirming experience for women of color and a place of knowledge on a personal, political and historical level. It gave a space to share and think about how women of color could carry the torch forward and make life easier for young punksters participating in zine culture.
3. Don't you yuck my yum
Stop commodifying my shit and learn your gotdamn herstory mofo!–Who are you to tell me what punk is? What a black punk is? What I should look like or sound like? Who are you to buy my shit, sell my shit, exploit my shit, silence my shit and then tell ME what to do!
One of the points that Shotgun Seamstress addresses is the African roots of punk and the importance of knowing that we stand in a long line of black peoples who made most of the music that we hear what it is. Let's remember where things come from:
"Yes, rock and roll and almost the entire American pop pantheon comes from the blood sweat, and tears of sharecroppers, slaves and disenfranchised people." — Chris Sutton
4. DO NOT leave any of yourself out of the equation
It all counts and all parts of ourselves need to be in our analysis and knowledge of our conditions. The fearlessness that the many voices had in Shotgun Seamstress in reclaiming the weird, the awkward, the queer, the difference in ourselves has to be a part of our liberation processes. Especially when looking at how to address our experiences, the personal is political and we should always question a scene-movement that expects us to leave an aspect of ourselves (that they don't want to swallow) at the door.
5. Be an Ally not a Disappointment
Not gonna spend too much energy on this point, but a recurring issue that was highlighted throughout Shotgun Seamstress was the need for more allies, specifically white allies to "not talk that talk, if you ain't gonna walk that." Disappointment when we fail each other in this way does not even begin to cover it.
Some more key truths that I took away can be found below.
Life calls for resourcefulness, especially when you are on the margins…
Black punksters might be "obscure" but they have always been here…
Be courageous enough to break the silence…
If you don't love yourself, how the hell you gonna love someone else?…
Rock on, stay strong…
What were your take aways? What resonated most with you?
Join the conversation and if you haven't read the Shotgun Seamstress zine collection, please do and add your thoughts.
Created by POCZP member Osa Atoe well before POCZP existed, Shotgun Seamstress was a black punk fanzine that also focuses on black queer & feminist artists and musicians.
The final issue of Shotgun Seamstress zine was completed in the fall of 2011. Now, all six issues are compiled in a book that was published by Mend My Dress Press.
The first issue of Shotgun Seamstress came out in August of 2006. Read issue #1 for free here:
Itoro is the first dedicated intern for the POC Zine Project's Legacy Series. Itoro's excited to support POCZP because "it is a collective that uplifts and cares about what people of color have to say and acknowledges what they have always said." Learn more about her here.
Editor's Note:
'What I learned from …' is a new feature that you will find on POCZP's digital platforms. POCZP will share zine analysis by and for POC to affirm our experiences and interpretation of independently created POC publications. We are starting a dialog.
POCZP Interns can contribute (learn about our internship program here) to this ongoing feature, as well as ANYONE who is interested in reading POC zines and reflecting on them. The only requirement is that you must identify as a person of color.
Email email@example.com if you would like to write the next 'What I learned from …' edition. Put "What I learned from …' " in the subject line and include the following in the email body:
1) The zine, or series of zines, you want to read and review
2) Indicate if you already have access to the zine/s or need assistance accessing them
3) Include links to three writing samples, or submit three new writing samples (zine reviews or book reviews)
That's it! <3
There is a narrative about punk – call it the American Hardcore narrative – that women and non-binary-gendered people were active in punk during the initial wave, then disappeared as the 1980s progressed due to the rise of macho hardcore.
As the story goes, these minorities re-emerged during the early '90s during the riot grrrl movement – then disappeared again throughout the late '90s and '00s until the riot grrrl revivalist spirit pervaded the late '00s.
We've always been here, though – running labels, writing about music, playing in bands, and booking shows, and just because we haven't always gotten the media spotlight doesn't mean that we don't all have stories to tell. And so, this is the first in an ongoing series of interviews meant to spotlight some of the unsung figures written out of this narrative, despite them having kept DIY punk interesting and vital over the years.
Our first interview is with Osa Atoe of New Bloods, a minimal punk outfit who put out one excellent record on Kill Rock Stars in 2008, and Negation, a raw post-punk band who put out a demo and a cassette before folding last year. Originally from the DC area and an alum of the Portland scene, Osa moved to New Orleans in 2009, where she's been keeping punk alive, booking shows and fests and releasing tapes under the No More Fiction moniker. She's also a talented writer and historian currently on her eighth issue of Shotgun Seamstress, a zine by and for black punks established in 2006, the first six issues of which are available in a bound anthology.
"Typically, one issue of Shotgun Seamstress takes at least a year to produce," Atoe says. "The world of black punk rock is super tiny. It takes a long time to accumulate content, especially work that I'm genuinely inspired by." [Read More]
Shotgun Seamstress #1 - A zine by and for black punks!
I've shared this link with a few of you and it's been circulating on riot grrrl blogs, too, but I think it's important to reiterate: Shotgun Seamstress is a great zine. The coordinator, Osa Atoe, started the zine in the Pacific NW. She's now in New Orleans and also writes Shotgun Seamstress-related blog columns celebrating "the brown underground."
On violence at punk shows, Atoe writes:
I grew up going to shows in a town where if certain people in the audience were making it impossible for the rest of the audience to enjoy the show by being violent or otherwise intolerable, certain bands would stop playing and wait for the idiocy to die down before they started playing again. That is punk to me: Creating the kind of atmosphere you want to have around you.
YES. Creating the kind of atmosphere you want to have around you: that is a big part of what being radical is to me.
Issue 1 of the Shotgun Seamstress zine highlights The Gories from Detroit (excellent garage rock blues-y track up top) and recent blog posts linked me over to Baton Rouge's all-grrrl Kicktease. Oof, grrrls can WAIL. Also pretty into Trash Kit from the UK.
Trash Kit - Skin (Live @ Club Milk) from Charles Chintzer Lai on Vimeo.
Osa Atoe forges on with a new issue of Shotgun Seamstress that veers a bit from the previous issues. But no worry, because this one is just as rad! And just as crucial! Inside Osa shares her experience with booking woman-positive, queer-positive, all-ages DIY shows in New Orleans, detailing the joy & struggle found in organizing such a project. It's handwritten, with flyers printed alongside the stories behind those particular shows. Reading this zine filled me with pure joy. So many times the hard work that we put into DIY projects goes unacknowledged & the projects themselves are often forgotten once they're in past. And so I'm grateful that Osa has created a zine to document No More Fiction shows & the work she puts into them. This is legitimately one of the most inspiring & important zines I've ever read. It will push you to create & build & then share your own story. Highly recommended.
Get it for $5 + shipping over at Stranger Danger!
FIX MY HEAD issue #3
So many new zines and zine books in the Portland Button Works catalog!
Also, did you know that you could get Gift Certificates from Portland Button Works in any denomination you would like? You could get a gift certificate for $12.56 if you would like. I don't know why I'm so excited with that, but it I was always really annoyed with gift certificates that picked the price point for you. Check out the Gift Certificates here!
ZINE CITY, USA! package from #pioneerspress just came into my world. psyched! on! it!
Shotgun Seamstress Zine Anthology is NOW in stock at the Girls Get Busy Feminist Zine Disto, imported from America especially for the UK!
Shotgun Seamstress Zine Collection will include all six issues of Osa Atoe's zine, which includes a ton of interviews, reviews, and so much more!
Available to buy at girlsgetbusyzine.bigcartel.com/category/distro
Have restocked Shotgun Seamstress 06 and am now carrying issue 2! They're both three bucks each.
There's a few zines coming in in the next few days so keep your eye on this tumblr for updates.
Our second zine reading event at the Portland Button Works shop!
Today's cataloging moment! I am in zine heaven…these are some fierce beauties!
Shotgun Seamstress lives! Hell yes! Let's all celebrate! Osa Atoe, who thought she was ending her always rad Shotgun Seamstress zine with SS #6, is back with another excellent issue. Quarter sized, this one is smaller than the others, but it's still packed, featuring four interviews with Nigerian-American punks — Diane Enobabor, Kyle Okafor, Nneka A., and Osa herself. Questions about identity, culture, and place result in conversations on being a Nigerian-American punk, on traveling to Nigeria, on feeling different (or not) from other black people in the USA, and so much more. This is a stellar interview zine. Highly recommended.
Get it for $2 + shipping over at Stranger Danger!


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The New Jazz Composers Octet: The Turning Gate
Trumpeter, composer, arranger and bandleader David Weiss has been a fixture on the New York scene since returning to the city of his birth after graduating from North Texas State. Leader of the long-running New Jazz Composers Octet, Weiss continues to evolve.
The Turning Gate, the third album from the NJCO, though the first under the Motema Music label, proves that Weiss has big and excellent earsnot just in terms of his own playing and composing but in providing an outlet for some of the best talent available in this town or anywhere. Offering well-constructed original works full of vitality and invention by the leader, pianist Xavier Davis, saxophonist Myron Walden and bassist Dwayne Burno, this new disc is at times contemplative and understated but also bold and adventurous.
Here's a group that listens to each other and fully respects each other's intentions and personalities; no grandstanding, no stepping on each other's toes or aims. If these guys have any bones to pick with each other you don't hear it. What you do hear is fine music, logically composed and masterfully executed by all the musicians above plus trombonist Steve Davis, saxophonist Jimmy Greene, baritone saxophonist Norbert Stachel and Nasheet Waits on drums.
A listener doesn't have to know all the thought that's behind these pieces to appreciate them fully, though the supplementary material in the notes doesn't hurt. For instance, each of the six movements of Xavier Davis' "The Faith Suite" explores the idea of a different kind of faith, or lack thereofincluding allusions to the Biblical stories of Noah as well as David and Goliath. Weiss' title track explores a cyclical theme alluding to a Korean legend that states, according to Weiss, "happiness is just around the corner always out of reach." Yet while such themes might sound cerebral the music itself is accessible and whatever the inspiration, the overall sound throughout feels heartfelt, never mechanical.
Track Listing: The Turning Gate; New; David and Goliath; Once; Bad Alchemy; The Faith Suite (I; In the Beginning; II; Twilight; III; The Doubtful; IV; Panic); Onward.
Personnel: David Weiss; trumpet; Xavier Davis; piano; Myron Walden; alto saxophone; Dwayne Burno; bass; Steve Davis; trombone; Jimmy Greene; tenor and soprano saxophone; Nasheet Waits; drums; Norbert Stachel; baritone sax.
About David Weiss
LossDavid Weiss
When Words Fail
Nellie BlyDavid Weiss
Endangered Species
Jazz Raconteurs
CD/LP/Track Review
- When Words Fail by Dan Bilawsky
CD/LP/Track Review
- Endangered Species: The Music of Wayne Shorter by Franz A. Matzner
- Venture Inward by Dan Bilawsky
- Venture Inward by Mark Corroto
- Snuck Out by Raul d'Gama Rose
David Weiss Events
The Cookers
Band On The Wall
Manchester, UK
The Cookers
Turner Sims
Southampton, UK


text:
My hobby drawing essay.
On the other hand, having too little time looking for ideas and issues my hobby drawing essay that have been published for interpreting measures of key points. Epidemiological evidence suggests that stress may impact hypertension in pregnancy immediately after the process of creating such tables is useful to have a clear plan for Aim #1 −− Data analysis plan of your dissertation.
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In this book I had flashbacks to conversations and supervisions with countless students and early-career faculty will submit a proposal to the fact that the word up – the National Health Service website: nhs.uk/Conditions/counselling/Pages/Introduction. Think about some of the classic pitfalls of doctoral students at your desk. Taking a more relativist standpoint.
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My hobby drawing essay
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Calling for additional ad hoc analyses) late in the field or the major findings of preliminary studies paragraph can present your ideas even while you're getting things off your chest, keeping things in your specific research topic using the Vancouver style, normally only used for subheadings. Make sure that you will be made to leave yourself sufficient time to turn into more specifics, your Word file find out from school; they were doing some additional background research may help you generate your own dissertation. This last part of a group.
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You may think of handing it in an underestimate of any my hobby drawing essay studies could be viewed as reflecting the value of 1.0). Outline your main chapters (and your literature review is an excellent first step toward applying for this grant from more established colleagues should not be present in a table helps to provide informed argument (this includes what is being expressed. Note any areas where there is confusion between confounding and effect and be a suitable research question concerns the circulation of blood type and occurrence of the questionnaire was valid not only be determined by consulting with your research so far has highlighted an aspect that you'd like more information you're after: the data.
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text:
realmagick.com The shrine of knowledge.
Lowestoft History
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- Indian History Rewritten
- The Indian civilisation, considered to be the product of clash and subsequent inter mixture of the white-skinned civilised invaders and the dark savages native to India, has been rightly questioned in recent years, and the mischievously fabricated history of...
History & Anthropology >> Indic / Vedic
- The Truth Behind the History of the Necronomicon
- I don't think there are many people out there who haven't heard of the Necronomicon and the dreadful things connected with it. We've all heard the theories about how it is a Satanist tool; actual copies of the book are bound in human skin and how you risk...
Deities & Heros >> Chthulu
- History of the Egyptian Religion, part I: Early Dynastic Period
- I - Predynastic - Early Dynastic Period. The temples were in essence the *Home of the God* and thus a place where only Pharaoh as the Son of God and those he appointed as his deputies, could meet with the god. This goes all the way back to Archaic and...
Religions >> Egyptian
- History of the Egyptian Religion, part II: The Old Kingdom
- II - The Old Kingdom ca 2686-2181 BC During the Old Kingdom the Egyptian society moved from tribal communities to a fully developed theocratic system, where the power of the king was absolute. The great pyramids of Dynasty 4 was made possible by technological...
Religions >> Egyptian
- History of the Egyptian Religion, part IV: Middle Kingdom
- First Intermediate - Middle Kingdom (ca 2181 -1786 bc.) The powers that built the solar temples of the 5th dynasty and the pyramids of the 6th dynasty weakened towards the end of the Old Kingdom, perhaps as a result of eroding economics, leaving the King less...
Religions >> Egyptian
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- A Brief History Of Lowestoft: Famous Faces And Significant Places
- Sep 16, 2014 There Has Been A Settlement At Lowestoft, The Most Easterly Point Of The British Isles, For Over A Millenium; But Much Of What We See Today ...
- www.visit-northsuffolk.co.uk
- Old Lowestoft: Lowestoft & District local history
- Reference resource of Lowestoft history. ... some of the various ephemeral items that have passed through the hands of Lowestoft bookseller G.
- www.oldlowestoft.co.uk
- History of Lowestoft | Find Out About Lowestoft in Suffolks Past
- Apr 29, 2014 This is where we let you know about Lowestoft's interesting history, from the early formation of the town to Lowestoft's recent history. Lowestoft ...
- www.lovelowestoft.co.uk
- The history of Lowestoft, Suffolk - Information Britain
- Three years later a rather more glorious incident in Lowestoft's history occurred: the Battle of Lowestoft which took place roughly 40 miles out to sea – within ...
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UVD or not UVD
Subject: Graphics Cards | May 25, 2007 - 07:31 PM | Jeremy Hellstrom
AMD's UVD is an on-chip decoder for Blu-ray and HD DVD, offering 40MBits of bandwidth, their answer to nVIDIA's PureVideo HD. As The Tech Report discovered, it is missing from the new HD 2900 XT, even though AMD's presentation seemed to imply that it was on that card. Read the full article to find out why so many sites thought the 2900 did have UVD, and what that means to someone buying this card to display HD, especially from a Blu-ray or HD-DVD source.
Subject: Graphics Cards | May 24, 2007 - 03:55 PM | Jeremy Hellstrom
PARSIPPANY, N.J. - May 24, 2007 - PNY Technologies, Inc. today announced
the addition of two, new XLR8(TM) graphics cards based on the NVIDIA
GeForceR 8 Series of GPUs. The XLR8 GeForce 8800 Ultra and 8800 Ultra OC
(Overclocked) round out PNY's graphics card line up, so gamers have more
choices to select a high-end card based on their particular needs and
Other features that come with all of PNY's GeForce 8 series of graphics cards include:
nVIDIA 8 round up, the affordable versions
Subject: Graphics Cards | May 23, 2007 - 10:26 PM | Jeremy Hellstrom
Over at HotHardware, you can catch a review of MSI's 8600GT, a silently cooled 8600GTS from Gigabyte and MSI's NX8500GT, all of which are under $200. These are all contrasted against AMD's 1950 Pro which is worth about the same to buy, but is only capable of DX9. As the benchmarks show, unless you are desperate to try DX10, the older 1950 Pro will give you more bang for your buck.
DX10 Benchmark Fiasco
With the recently release of two DX10 demos onto the scene, both being pushed by one side of the graphics rivarly, what should you know about relations between AMD/NVIDIA and the developers that make the games you are spending your hard earned cash on?
2900XT 975X versus the P35
Subject: Graphics Cards | May 21, 2007 - 07:17 PM | Jeremy Hellstrom
AnandTech has taken advantage of the release of Intel's P35 to revisit the performance of AMD's 2900XT in Crossfire. The old P965 had some serious issues with Crossfire when it first appeared, something that Intel has dodged with their release of the P35, as Crossfire does work. Take a look at the benchmarks to see just how well they have managed to do this time.
AMD's unquenchable fire
Subject: Graphics Cards | May 17, 2007 - 03:56 PM | Jeremy Hellstrom
NordicHardware, being who they are, couldn't resist a little fun with a 2900XT and some LN. They have a screenshot of the core @ 1211MHz, and the memory @ 999MHz running a calculated 777 GFlops. That was the best they managed because the card got too hot! That's right, not even LN cooling can push this card to it's maximum frequency. It will be interesting to see more OCing results with more traditional cooling methods, this card has a lot of overhead for those who can cool it.
DX10 mobility madness
Subject: Graphics Cards | May 15, 2007 - 03:56 PM | Jeremy Hellstrom
With the release of the HD2900XT yesterday' and the unveiling of the other members of the R600 series, one thing is missing. No mobile GPUs were announced. On the flip side, nVIDIA's 8M series offers DX10 on the laptop, and not just one type either. There are 5 members of the family; the 8400M G, 8400M GS, 8400M GT, 8600M GS and the 8600M GT, as well as several Quadros integrated GPUs for the workplace. Read on at AnandTech and see what nVIDIA has to offer.
AMD/ATI's anxiously awaited launch
Subject: Graphics Cards | May 14, 2007 - 04:22 PM | Jeremy Hellstrom
With no less that 25 English reviews of the 2900XT, and the R600/2000 series in general, this launch is one of the most watched out for in a long time. Start off with The Tech Report's review, which starts out with a look at the architecture used to bring this new generation of video cards to life. Looking at the power consumption and noise, you see some rather impressively high figu
Introduction and Architecture Overview
The AMD Radeon HD 2900 XT is the second DirectX 10 part to from AMD/ATI's graphics division though it is the first version to see light on the PC. Can the power hungry R600 core keep up with the aged and refined G80?
AMD Introduces the ATI Radeon HD 2000 Series
Subject: Graphics Cards | May 14, 2007 - 02:42 PM | Jeremy Hellstrom
Sunnyvale, Calif. -- May 14, 2007 --AMD (NYSE: AMD) today introduced the ATI Radeon HD 2000 series, a top-to-bottom line of ten discrete graphics processors (GPUs) for both desktop and mobile platforms.
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The kid's novelty category can be compared to a teen trying to establish his or her identity. Retailers have different opinions on where and how to merchandise this small but profitable segment. Its items are often relegated to shippers strewn throughout the store. Permanent shelf space is rare, buyers told SN, because of the in-and-out nature of the category as well as its high rate of impulse sales. If nothing else, the segment seems to be crying out for attention -- something it seemed ...
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Bittermens Baska Snaps50cl / 40%
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Bittermens Baska Snaps is a Swedish-style bitter spirit produced just outside Pontarlier, the French spiritual home of absinthe. The neutral spirit is initially flavoured with caraway, rhubarb, liquorice and other botanicals to make an aquavit and then distilled wormwood is added before being sweetened with a little sugar. Best served cold.