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Pelvic floor training for urinary incontinence

Specific description is often missing in papers

  • Advice to authors: offer protocols and patient information online
  • Reproducibility of pelvic floor therapy below par 
  • Bad description does not equal bad therapy

Pelvic floor therapists are mainly depending on their own clinical experience when it comes to prescribing pelvic floor exercises to women with urinary incontinence. The description of the interventions in high quality research is substandard. The way researchers adjust the pelvic floor therapy to the individual and a description of the presumed working mechanism of the exercise therapy are often missing. This is concluded by Canadian scientists who assessed the intervention descriptions of eighteen recent randomised and controlled studies of adequate quality with three validated measurement tools.

Individual adjustments

The way researchers customised the therapy to the individual patient, was even more unclear. As an example, the authors mention personalising the advice for pelvic floor contractions. They state that patients who experience urinary incontinence during sneezing or coughing, have more benefit with exercising brief powerful contractions of the pelvic floor, whereas women who struggle more with urinary incontinence as physical effort progresses, should train longer contractions of pelvic floor muscles. However, according to the authors, in a lot of scientific studies these personalised advices are lacking. 

Quality

The authors state that a poor description of the intervention does not automatically mean that the quality of the intervention itself is poor. In a previous study in which the authors contacted the researchers, it was shown that non reported details were executed in a good way. Authors give the word limit in a lot of scientific magazines as a possible explanation for the deleting of detailed descriptions of the method. 

> From: Charette et al., Neurourol Urodyn 39 (2020) 35-44 . All rights reserved to Wiley Periodicals, Inc. Click here for the online summary. Translation by Casper Martens

Outcomes measures

The ‘Consensus on Exercise Reporting Template’ (CERT) and the ‘Template for Intervention Description and Replication’ (TIDieR) consist of sixteen and twelve items, respectively, that should be described to make an exercise therapy intervention reproducible. They include the usage of tools, a description of the therapist who prescribes or guides the exercises, dosage of the exercises, therapy compliance and the adjustments to specify on the individual, among other things. 

The ‘Consensus on Therapeutic Training’ (CONTENT) scale consists of nine items to judge the validity of an intervention. The scale includes the categories: in- and exclusion criteria, competence of the therapist and the setting in which the therapy is conducted, the rationale behind the therapy, the description of the content of the intervention and therapy compliance. 

Expert opinion by Marijke Slieker-ten Hove

A wonderful article which clearly puts the finger on the sore spot. In many studies we don’t know the type of intervention due to terms like ‘pelvic floor training’ or a standard of 3 series of 12 seconds or any variation whatsoever. Experience tells us that an individual programme should be custom made based on the function at the start of the therapy. ‘Tailor made’ so to say. Nevertheless, this can be found in only few studies. The ‘why’ is often missing and the motivation or substantiation of the choice for 10, 20 or 30 seconds is often unclear. 

But there are more comments for future researchers. A lot of studies, actually do state who conducted the therapy: “an experienced pelvic floor physiotherapist”, “an experienced nurse”, “an experienced physiotherapist” or “an adequately trained doctor.” The definition of “experienced” or “adequately trained”, however, remains unclear. The International Continence Society has already tried to classify the level of education, by specifying the level of pelvic floor education that must be met. This turns out to be extremely complicated, and can be poorly checked or aligned per country. Yet, the need is huge to indicate as detailed as possible who performs the treatment, what the level of knowledge is, what is done exactly and what the exercise physiological rationale is. 

Are pelvic floor therapists the only ones in this? No, for example, there were studies published years ago in Great-Britain and The Netherlands investigating gynaecological surgical interventions. These showed that it depends on the doctor and the hospital which techniques were used. The techniques were mentioned most of the time, but upon inquiry the gynaecologist says: it is tailor made and that must stay that way. But this results in a difficult comparison of interventions. Perhaps, we as pelvic floor physiotherapists should give more attention to what we do exactly, so descriptions should state clearly what is actually done in a tailor made programme. In the end, that is what we do, and it gives the reader more insight. And above all: it gives us better options for scientific research. 

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