Hypothesis / aims of study
Urinary incontinence (UI) is one of the most prevalent health concerns among women aged 65 and over. The recommended first-line treatment for UI is individual pelvic floor muscle training (PFMT). [1] Yet, this treatment appears to be a resource-intensive approach that healthcare systems across the world are currently unable to meet. Recently, group-based PFMT was shown to be non-inferior to individual PFMT to treat UI in older women, despite using fewer resources. While group approaches thus appear promising, public health measures restricted group gatherings and interventions during the COVID-19 pandemic, which highlighted the importance of remote options. Therefore, this study aimed to assess the feasibility of online group PFMT for UI in older women.
Study design, materials and methods
This mixed-methods clinical study investigated acceptability and feasibility from multiple stakeholders’ perspectives, in addition to the short- and long-term clinical effects of online group PFMT on UI and UI-related symptoms. This abstract presents the study’s feasibility component from the perspectives of the participants and the physiotherapist.
Population
We recruited community-dwelling women aged 65 and over, with symptoms of stress or mixed UI for three months or more, who reported at least three weekly episodes of urine leakage on a bladder diary. Stress/mixed UI was confirmed with the Questionnaire for Urinary Incontinence Diagnosis (QUID). [2] All participants were required to have internet access. Exclusion criteria included a body mass index (BMI) ≥ 35; significant pelvic organ prolapse (Baden-Walker score > 2); physiotherapy treatment or surgery for UI or pelvic organ prolapse in the past year; any medication, co-morbidities or risk factors known to interfere with the effects of PFMT or with the pelvic floor muscle (PFM) evaluation.
Intervention
Pelvic floor physiotherapists established the eligibility of participants during an individual in-person initial evaluation session, where they also taught the participants how to contract their PFMs correctly through vaginal digital palpation.
Participants then took part in a 12-week online group-based PFMT program consisting of weekly one-hour training sessions from their home. A 13th optional session was offered at the end of the program as a catch-up session for any missed training. All participants received an exercise booklet, detailing the exercises and their progression, and a physical copy of the educational component of each session. An experienced pelvic floor physiotherapist delivered all sessions via Zoom to groups of seven to 11 women. Each session began with a one-to-three-minute individual meeting with the physiotherapist in a private breakout room to discuss weekly leakages and exercise adherence, while the rest of the group socialized in the ‘main room’ of the Zoom meeting. The session was then divided into a 10-15-minute educational component and a 30-45-minute PFM exercise component. The educational component covered various topics relevant to the aging pelvic floor as well as UI and pelvic health. The exercise component included four PFM exercises with a gradual increase in duration, difficulty, repetition and position (from lying down, to sitting, to standing). In addition to their attendance to the weekly sessions, participants were also expected to perform PFM exercises at home, for a total of five-days/week, during the intervention. Upon completion of the 12-week program, participants were asked to commit to a maintenance exercise regimen for six months.
Data collection
Data was collected before and throughout the 12-week intervention.
We collected baseline and demographic data before the intervention, including data on age, BMI, gynecological history and UI symptom severity with the ICIQ-UI SF and the Australian Pelvic Floor Questionnaire (APFQ). [3]
To assess the program’s feasibility, we collected data on participant attendance to the online sessions, dropout rates and reasons for dropping out, program fidelity as delivered by the physiotherapist, participant adherence to weekly home exercises and any reported side effects throughout the 12-week intervention period.
Data analysis
We reported baseline and demographic data, attendance, dropout rates, program fidelity, participant adherence and side effects narratively and using descriptive statistics.
Results
Description of the participants
From March 2021 to April 2022, a total of 34 older women were recruited to participate in the online group PFMT program and divided into four groups. Participants had a mean age of 70.1 (SD 4.2) years and a mean BMI of 25.3 (SD 4.0). Among them, mean parity was 1.4 (SD 1.2). Additionally, 44% used post-menopausal hormone therapy with a mean of 10 years of use. They had moderate UI symptoms before the intervention, with a median of 12 weekly leakages, and mean scores of 11.9/21 (SD 3.4) on the ICIQ-UI SF and 15.5 (SD 0.9) on the UI subscale of the APFQ [3]. The mean duration of UI symptoms was 12.9 (SD 15.5) years. Thirty-two (94.1%) had symptoms of mixed UI, and two (5.9%) of stress UI only.
Feasibility
Program attendance was excellent (91%) with an average of 12/12 (SD 1) attended sessions. Only one participant dropped out (3%) due to personal reasons. The program fidelity was overall good, with only minor adaptations noted to the program. The most important adaptation was an increase in the time allocated to the individual meeting period. This led to a 10- to 20-minute increase in the session’s duration, depending on the number of women in the group. Additionally, the optional core and pelvis exercises were frequently skipped due to time constraints, while PFM exercises were prioritized. Lastly, the physiotherapist limited position changes during the sessions in order to avoid multiple camera angle adjustments by both the physiotherapist and women and to reduce time spent correcting participants’ posture. The exercises performed during the weekly sessions were thus less varied and more like the home exercise program. Home PFM exercises were performed four to five times/week by 94% of the participants during the 12-week intervention period. No side effects were reported, apart from muscle soreness during the first weeks of training for one participant.
Interpretation of results
The high attendance compares favourably with previously reported attendance for in-person trials, showing good engagement from the older women in online treatment. Attrition was low, which is also in line with previous in-person interventions, showing no reduction in commitment to remote trainings. Fidelity was good and the physiotherapist was able to follow most of the program’s steps, although the variety of exercise types and positions were reduced due to time constraints. The observed adaptations reflected the clinical judgement of the leading physiotherapist, who selected the most relevant exercises for PFM strengthening, considering the participants’ levels and available time. Adverse events were minor and uncommon, also echoing previous findings from in-person interventions and supporting the safety of this program.