The aim of this study is to assess if the efficacy of a fully digital physiotherapy program for treating urinary incontinence (UI) can be influenced by whether women have previously undergone face-to-face treatment or not. The hypothesis is that women who have already undergone an in-person intervention in the past may be more aware of the pelvic floor and, therefore, achieve better results.

This is a secondary analysis from a semi-experimental study developed from February 2021 to April 2022, at a public teaching hospital in Brazil. The study followed the TREND recommendations, the Brazilian Guidelines for virtual research, and the recommendations for digital physiotherapy practices, provided by the Brazilian Federal Council of Physical Therapy and Occupational Therapy (COFFITO) and by the Brazilian Association of Physical Therapy in Women's Health (ABRAFISM). The study was approved by the institutional Ethics Committee. The outcome of interest was the severity of urinary incontinence symptoms assessed by the final score of International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF).  In the mentioned period, patients who underwent a gynecological appointment complaining of UI were referred to pelvic floor physiotherapy by the Gynecology Outpatient Clinic team. Women were prescreened by telephone to be informed about the intervention and to check for eligibility. Inclusion criteria were females with UI, 18 years older, and who had digital access to join a videocall weekly. Exclusion criteria were being in physiotherapeutic treatment or have undergone a rehabilitation program in the past 6 months. Medical records were checked to rule out conditions such as pelvic organ prolapse greater than grade 2, neurological diseases and abdominopelvic surgery/childbirth in the past year. A pilot study was done in the main study to determine a proper sample to detect significant improvement of UI symptoms based on ICIQ-SF final score. Power and Sample Size for Health Researchers (PSS Health) software - online version was used. Considering a power of 95%, a significance level of 5%, and adding 30% for possible losses, the sample size resulted in 20 participants. All data collection was carried out exclusively digitally due to the pandemic restrictions adopted at the time of data collection. Participants received the Consent Form on WhatsApp messaging app. They were instructed to write back "I voluntarily agree to participate in this study", if that was the case. This method of consent was defined by the hospital Ethics Committee. Then, they underwent a prescheduled phone call to check for demographic data, UI symptoms and to answer the ICIQ-SF, which is a three-scored questions questionnaire concerning frequency, amount of leakage, and overall discomfort from 0-10. The score grades from 0 to 21, with higher score indicating greater severity of UI symptoms. At the end of treatment, another phone call was scheduled to reassess UI symptoms and to reapply the ICIQ-SF questionnaire. Phone calls were performed by a student who was not involved in the videocalls so participants would feel comfortable giving their opinion. WhatsApp groups with no more than 5 participants (plus one physiotherapist) were organized. Groups were created to enable a good communication between the participants and the researcher. Women received a reminder 30 minutes before every meeting to encourage adherence to treatment. An 8-week digital group physiotherapy intervention was done once a week, in a 30-minute synchronous video call, supervised by a physiotherapist with expertise in pelvic floor dysfunctions (PFDs). All sessions started with a 20-minute conversation about lifestyle modification for PFDs, followed by 10-minutes of exercises (breathing and pelvic mobility exercises, pelvic floor muscle training and stretching exercises). A chatting space was stimulated, and women were encouraged to share their experiences and ask questions. For reference at home, all provided information was forwarded in digital files in the end of each meeting, according to what was discussed. The exercise protocol was sent to the participants digitally and they were oriented to perform it at home three to four times a week. Data were tabulated by the double-key entry method and analyzed in IBM® SPSS® Statistics. A simple linear regression was performed to assess whether the prior experience of undergoing an in-person physiotherapeutic intervention for treating urinary incontinence in the past influences the outcomes of a digital treatment. For this analysis, the predictor independent variable was having undergone physiotherapy before or not (categorical binary variable) and the dependent variable was the difference between the ICIQ-SF questionnaire score before and after treatment.

49 women were included in this analysis. Of those, 18 had already undergone a face-to-face appointment with a pelvic health physiotherapist in the past. There were no differences regarding age, body mass index, pregnancies, and ICIQ-SF score at baseline between women who had been referred to a pelvic health physiotherapist before and those who had not (Table 1). According to the ICIQ-SF scoring, all participants improved from severe symptoms at baseline (15±3.2) to moderate symptoms after the treatment (12±4.9), p<0.001. The simple linear regression showed that having undergone an in-person physiotherapy treatment before does not influence the final outcome provided by a digital intervention [F(1,47) = 0.148, p=0.702, R2=0.003].

Having undergone an in-person intervention in the past doesn’t seem to influence the results of a fully digital physiotherapeutic intervention for treating female UI. Our findings support this method even if the only alternative would be developing the entire treatment remotely. As access to pelvic floor physiotherapy is not a reality everywhere, a digital program can be an alternative to manage UI in remote areas. Adopting this model would be interesting especially in referral hospitals where patients from other locations are admitted.

A digital group physiotherapy intervention is an alternative to be further explored for the treatment of female UI. PFMT has strong evidence for UI treatment, so distance should not be a limiting factor. A proper PFM assessment should be performed always as possible, however, treatment for UI should still be encouraged, regardless of whether a face-to-face assessment is viable.

Continence 7S1 (2023) 100946
DOI: 10.1016/j.cont.2023.100946