Challenges in applying evidence-based practice in stroke rehabilitation: a qualitative description of health professional experience in low, middle, and high-income countries.

Purpose: Evidence-based practice (EBP) is considered central to ethical, effective service delivery in rehabilitation, and the implementation of the World Health Organisation's Rehabilitation Strategy 2030. This study aimed to explore and compare the experiences of health professionals regarding the application of EBP for stroke rehabilitation in each participant's region and country, which provided perspectives from low, middle, and high-income countries.Methods and materials: Interviews were conducted with 12 experienced rehabilitation professionals from 12 different countries (5 high-income, 2 upper-middle income, 3 lower-middle income, and 2 low-income countries) and interpreted using qualitative descriptive analysis.Results: Nine factors influencing evidence-based stroke rehabilitation were: 1) the complexity of rehabilitation research; 2) the (ir)relevance of research to local context; 3) lack of time for EBP; 4) minimal training in EBP; 5) changing health professional behaviours; 6) poor access to resources for developing EBP; 7) influence of culture, patients, and families; 8) language barriers; and 9) lack of access to research evidence. Economic constraints contributed to many challenges; but not all challenges related to the country's economic classification.Conclusion: A global approach is needed to share knowledge about EBP, especially scientific evidence and innovative thinking about its application to clinical practice. Implications for rehabilitationRehabilitation professional groups should contribute to a global network to improve informal knowledge sharing and training around evidence-based practice.Support for training in evidence-based practice and its application needs to be developed and accessible in all countries, including low and middle-income countries.It is imperative that policymakers prioritise practical, evidence-based solutions for rehabilitation research in low and middle-income countries that can be effectively implemented within local settings.There must be solutions and increased accessibility of journal articles for those working in low and middle-income countries including those whose first language is not English.

Women's preferences for pelvic floor screening in sport and exercise: a mixed-methods study integrating survey and interview data in Australian women.

OBJECTIVES: One in two women experiencing pelvic floor (PF) symptoms stop playing sport or exercising. The study examines the perspective of women with PF symptoms to inform acceptable screening practices within sport and exercise settings. METHODS: Explanatory, sequential, mixed-methods design. Phase 1: survey of 18-65 years, symptomatic, Australian women (n=4556). Phase 2: semistructured interviews with a subset of survey participants (n=23). Integration occurred through connection of phases (study design, sampling) and joint display of data. RESULTS: Findings are represented in three threads: (1) 'women (not) telling'; a majority of women had told no-one within a sport or exercise setting about their PF symptoms due to shame/embarrassment, lack of pelvic health knowledge and not wanting to initiate the conversation, (2) 'asking women (screening for PF symptoms)'; women endorsed including PF symptom questions within existing sport and exercise screening practices but only when conducted in a respectful and considered manner and (3) 'creating safety'; professionals can assist women to disclose by demonstrating expertise, trustworthiness and competency. If health and exercise professionals are provided with appropriate training, they could raise pelvic health awareness and promote a supportive and safe sport and exercise culture. CONCLUSION: Women with PF symptoms support health and exercise professionals initiating conversations about PF health to normalise the topic, and include PF symptoms among other pre-exercise screening questions. However, women should be informed on the relevance and potential benefits of PF screening prior to commencing. Safe screening practices require building trust by providing information, gaining consent, displaying comfort and genuine interest, and being knowledgeable within one's scope of practice to the provision of advice, exercise modifications and referral as appropriate.

Exploring the Use of the Behavior Change Technique Taxonomy and the Persuasive System Design Model in Defining Parent-Focused eHealth Interventions: Scoping Review.

BACKGROUND: Taxonomies and models are useful tools for defining eHealth content and intervention features, enabling comparison and analysis of research across studies and disciplines. The Behavior Change Technique Taxonomy version 1 (BCTTv1) was developed to decrease ambiguity in defining specific characteristics inherent in health interventions, but it was developed outside the context of digital technology. In contrast, the Persuasive System Design Model (PSDM) was developed to define and evaluate the persuasive content in software solutions but did not have a specific focus on health. Both the BCTTv1 and PSDM have been used to define eHealth interventions in the literature, with some researchers combining or reducing the taxonomies to simplify their application. It is unclear how well the taxonomies accurately define eHealth and whether they should be used alone or in combination. OBJECTIVE: This scoping review explored how the BCTTv1 and PSDM capture the content and intervention features of parent-focused eHealth as part of a program of studies investigating the use of technology to support parents with therapy home programs for children with special health care needs. It explored the active ingredients and persuasive technology features commonly found in parent-focused eHealth interventions for children with special health care needs and how the descriptions overlap and interact with respect to the BCTTv1 and PSDM taxonomies. METHODS: A scoping review was used to clarify concepts in the literature related to these taxonomies. Keywords related to parent-focused eHealth were defined and used to systematically search several electronic databases for parent-focused eHealth publications. Publications referencing the same intervention were combined to provide comprehensive intervention details. The data set was coded using codebooks developed from the taxonomies in NVivo (version 12; QSR International) and qualitatively analyzed using matrix queries. RESULTS: The systematic search found 23 parent-focused eHealth interventions described in 42 articles from various countries; delivered to parents with children aged 1 to 18 years; and covering medical, behavioral, and developmental issues. The predominant active ingredients and intervention features in parent-focused eHealth were concerned with teaching parents behavioral skills, encouraging them to practice and monitor the new skills, and tracking the outcomes of performing the new skills. No category had a complete set of active ingredients or intervention features coded. The two taxonomies conceptually captured different constructs even when their labels appeared to overlap in meaning. In addition, coding by category missed important active ingredients and intervention features. CONCLUSIONS: The taxonomies were found to code different constructs related to behavior change and persuasive technology, discouraging the merging or reduction of the taxonomies. This scoping review highlighted the benefit of using both taxonomies in their entirety to capture active ingredients and intervention features important for comparing and analyzing eHealth across different studies and disciplines. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-doi.org/10.15619/nzjp/47.1.05.

Documented incontinence after stroke: a secondary analysis of a cohort study. Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care).

AIM: To estimate the prevalence of incontinence after stroke in Aotearoa New Zealand overall and by ethnicity, the associations between incontinence and subsequent mortality and living in residential care, and to estimate the health utilities in relation to continence. METHOD: Secondary analysis of data from a prospective (1 May to 31 July 2018) cohort study (REGIONS Care study) of patients with a confirmed stroke admitted to New Zealand hospitals. Logistic and linear regression were used, and multivariate models were adjusted for age, sex, ethnicity, and stroke severity. The association between living in residential care, incontinence, and mobility was also assessed. RESULTS: There were 320/2,377 (13.5%) patients with documented incontinence during hospitalisation after stroke. Incontinence was not associated with ethnicity but was associated with increased mortality/living in residential care, at discharge, three, six and twelve months after stroke. Stroke survivors with independent mobility were more likely to live in residential care if incontinent. Health utility scores were lower at three, six and twelve months for those with incontinence after stroke. CONCLUSION: This study likely underestimated incontinence prevalence after stroke, although incontinence was associated with increased mortality and probability of living in residential care.

Narrative review of pelvic floor muscle training for childbearing women-why, when, what, and how.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is prevalent during pregnancy and postpartum. UI in pregnancy strongly predicts UI postpartum and later in life. UI reduces women's wellbeing and quality of life and presents a significant burden to healthcare resource. METHODS: A narrative review summarizing quantitative and qualitative evidence about pelvic floor muscle training (PFMT) for prevention and treatment of UI for childbearing women. RESULTS: There are clinically important reductions in the risk of developing UI in pregnancy and after delivery for pregnant women who start PFMT during pregnancy, and PFMT offers additional benefits preventing prolapse and improving sexual function. If women develop UI during pregnancy or postpartum then PFMT is an appropriate first-line treatment. For novice exercisers, a programme comprising eight contractions, with 8-s holds, three times a day, 3 days a week, for at least 3 months is a reasonable minimum and 'generic' prescription. All women need clear accurate verbal instruction in how to do PFMT. Incontinent women, and women who cannot do a correct contraction, require referral for pelvic floor rehabilitation. Behavioural support from maternity care providers (MCPs)-increasing women's opportunity, capability, and motivation for PFMT-is as important as the exercise prescription. CONCLUSION: PFMT is effective to prevent and treat UI in childbearing women. All pregnant and postpartum women, at every contact with a MCP, should be asked if they are continent. Continent women need exercise prescription and behavioural support to do PFMT to prevent UI. Incontinent women require appropriate referral for diagnosis or treatment.

A self-report questionnaire for pregnancy-related symphyseal pain.

BACKGROUND: Symphyseal pain (SP) experienced during pregnancy is a common condition that can negatively influence function and wellbeing. Despite its adverse impact on quality of life, standardised diagnostic criteria for SP as a distinct type of pelvic girdle pain (PGP) are lacking. OBJECTIVES: To develop a reliable self-administered instrument that could differentiate SP from posterior PGP in pregnant women, and ultimately be used for epidemiological or clinical purposes. METHOD: Qualitative data from 17 women (four focus groups) were used to develop a questionnaire. The questionnaire was tested against physical therapy diagnoses based on clinical assessment in 122 pregnant women with SP (n = 41), posterior PGP (n = 41) or no PGP (n = 40); 30 women repeated the questionnaire a day later to assess reliability. Multinomial logistic regression models were used to assess the performance of candidate items in distinguishing between the groups. RESULTS/FINDINGS: The single questionnaire item relating to location of worst pain (diagrammatic form) is useful for differentiating SP from posterior PGP and individuals with no PGP. The worst pain location question with the addition of the Pelvic Girdle Questionnaire provides a measure of "SP with impact", and is the best combination for distinguishing SP and posterior PGP. Test-retest reliability scores were excellent. CONCLUSION: These findings provide new opportunities for diagnosing pregnancy-related SP, and highlight questionnaire items which best differentiate SP from posterior PGP. These items could be used in future epidemiological research, and in clinical settings as a quick, effective screening tool.

Using a citizens' jury approach to determine a good nutrition resource for pregnant women.

OBJECTIVE: The development of user-friendly nutrition resources for pregnant women seldom involves end-users. This qualitative study used a citizens' jury approach to determine if our modification of a longstanding, frequently used dietitian-informed diet and diabetes booklet was deemed to be a good healthy eating resource for pregnant women. DESIGN: Midwives recruited thirteen first-time pregnant women not requiring specialist obstetric care or specialist dietetic advice for any reason. Participants were sent a copy of the modified healthy eating in pregnancy booklet prior to 'jury day'. Five women were unable to attend the citizens' jury citing reasons such as early labour. At the jury, five experts presented evidence. Participants adjourned, with an independent facilitator, to 'deliberate' as to whether the resource was suitable or not. The verdict was presented, and subsequent discussion was audio-recorded, transcribed and inductively content analysed. SETTING: Southland, New Zealand. PARTICIPANTS: Pregnant women aged 19-35 years (n 8), of whom half had a household income <$NZ30 000. RESULTS: The verdict was 'Yes'; the resource was good. Three themes were derived: communication of health information, resource content and harm reduction in pregnancy. Based on these data, ways to enhance the quality and usability of the booklet were evident. CONCLUSIONS: Citizens' juries can be used to obtain an independent assessment by end-users of health resources. Our modified diet and diabetes booklet was considered suitable for providing healthy eating advice to pregnant women. Inclusion of end-users' perspectives is critical for end-user relevant content, comprehension and resource credibility.

Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women.

BACKGROUND: About one-third of women have urinary incontinence (UI) and up to one-tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence. This is an update of a Cochrane Review previously published in 2017. OBJECTIVES: To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies. SELECTION CRITERIA: We included randomised or quasi-randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment). DATA COLLECTION AND ANALYSIS: We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE. MAIN RESULTS: We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately-sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT. Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate-quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high-quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low-quality evidence). Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low-quality evidence), or in the mid-(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low-quality evidence), or late postnatal periods (very low-quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low-quality evidence). Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate-quality evidence), and may reduce the risk slightly in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low-quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate-quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate-quality evidence). Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low-quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate-quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low-quality evidence). There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. AUTHORS' CONCLUSIONS: This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.

Wrestling with uncertainty after mild traumatic brain injury: a mixed methods study.

Purpose: Our objective was to explore the intersection between mild traumatic brain injury (MTBI) recovery experiences and injury understandings, using both quantitative and qualitative methods.Materials and Methods: The quantitative component was a descriptive case-control study comparing participants (n = 76) who had recovered or not recovered after an MTBI, across demographic and psychological variables. A subset of participants (n = 10) participated in a semi-structured interview to explore experiences of recovery in more detail. We followed threads across the datasets to integrate findings from component methods.Results: The quantitative analyses revealed differences between the two groups in terms of injury recovery understandings and expectations. The qualitative analyses suggested that achieving consistency across information sources was important. By tracing threads back and forth between the component datasets, we identified a super-ordinate meta-theme that captured participants' experiences of wrestling with uncertainty about their recovery and the impacts in terms of heightened anxiety, confusion, and feelings of invalidation.Conclusion: The effectiveness of psychoeducation and reassurance after MTBI may be optimized when content is tailored to the individual. Clinicians are urged to attend both to the subjective interpretations patients make of information gained from formal and informal, internal and external sources, and where information across these sources conflicts and creates uncertainty.Implications for rehabilitationEffectiveness of psychoeducation and reassurance after injury may be optimized when content is tailored to the individual rather than being generic.Effectiveness of such interventions may also be optimized by understanding the subjective interpretations individuals make of injury knowledge gleaned from formal and informal, internal and external sources.Conflicting information from such multiple sources may create uncertainty with associated increased distress as an individual negotiates their recovery from injury. Attending to this uncertainty may be a helpful target for treatment.

Intuitive eating and gestational weight gain.

This observational study was designed to establish whether there is a relationship between intuitive eating and gestational weight gain. Intuitive eating involves eating according to hunger and satiety cues, rather than following diet rules or eating in response to external triggers or emotions. Higher levels of intuitive eating are associated with bodyweight in the normal range in women during young and middle adulthood. Excess gestational weight gain is associated with an increased incidence of adverse health outcomes for mothers and children, including many pregnancy related conditions and, following pregnancy, an increased likelihood of obesity among mothers and children. Pregnant women were recruited at their nuchal translucency scan (11-14 weeks gestation), in Dunedin, New Zealand, between 2013 and 2015. A cohort of 218 women completed questionnaires at four times during their pregnancies. Intuitive eating was measured using a version of the Intuitive Eating Scale (IES) adapted for pregnant women and revalidated with this population. Gestational weight gain was calculated at the term visit (>35 weeks gestation) and babies' birth weight was established from the electronic maternity system. Mean total IES scores (and all IES subscales) increased across pregnancy. For every one point greater total IES score at baseline, there was a 1.7 (0.5, 2.9) kg lower gestational weight gain. There was no association between babies' birth weight and intuitive eating. Intuitive eating appears to be associated with lower gestational weight gain but not babies' birth weight. It remains to be seen whether intuitive eating can be increased by educational interventions during pregnancy and thus have an impact on gestational weight gain.

Compared to what? An analysis of the management of control groups in Cochrane reviews in neurorehabilitation.

BACKGROUND: Control groups are used in clinical trials to increase confidence that any improvements in patient outcomes are due the therapy under investigation and not to other factors. The reported effect size of any intervention is estimated from differences in outcomes achieved by intervention participants in comparison to control participants. Clinical heterogeneity in control groups across different studies can make the pooling of data from these studies in one meta-analysis questionable or reduce certainty in their results. AIM: The aim of this study was to evaluate: 1) the variability in the types of control groups used in studies that have been pooled in meta-analyses in Cochrane reviews on neurorehabilitation interventions; and 2) how authors of Cochrane reviews on neurorehabilitation interventions have taken information about control groups into consideration when making decisions to undertake meta-analyses and interpreting their results. METHODS: We searched the Cochrane library for reviews on neurorehabilitation interventions published between 2012 and 2016 that included at least one meta-analysis involving a control group. We extracted data from included reviews on the review characteristics, the characteristics of the included meta-analyses, and any information on how the review authors managed control groups in the conduct and interpretation of meta-analyses. RESULTS: The 43 included reviews pooled data from 358 clinical trials, with an average of 5±5 clinical trials (range: 2-45) contributing to each meta-analysis. The majority of clinical trials involved a control group containing active treatments (61.7%; 221 of 358), often "treatment as usual" controls without any additional placebo or sham intervention. Over half (58.1%; 25 of 43) of the included meta-analyses involved pooling of data from studies with a mix of different types of control groups, with an additional 25.6% pooling data from studies where control participants had received a range of different active treatments. The influence of different control groups on the summary results from meta-analyses was not analyzed in 21 (48.8%) of the included reviews. CONCLUSIONS: Further work is needed to develop: standardized ways to categorize control conditions in rehabilitation trials; more guidance on reporting criteria for control groups in rehabilitation trials; and agreed methods for managing different control types in one meta-analysis.

The Consensus on Exercise Reporting Template (CERT) in a systematic review of exercise-based rehabilitation effectiveness: completeness of reporting, rater agreement, and utility.

BACKGROUND: Rehabilitation interventions are diverse - making decisions about pooling data in meta-analyses challenging. Intervention reporting templates such as the Consensus on Exercise Reporting Template (CERT) may help reviewers document intervention variability. AIM: To assess inter-rater agreement and utility of CERT used to assess completeness of reporting of one rehabilitation exercise intervention: pelvic floor muscle training (PFMT). DESIGN: A non-experimental agreement study. SETTING: Update of the Cochrane systematic review comparing different approaches to PFMT for urinary incontinence in women. POPULATION: Two PFMT arms from 21 newly identified trials. METHODS: Five raters independently used CERT to assess sufficiency of reporting of each arm (experimental PFMT and control PFMT) of each trial. One rater, PFMT non-expert, rated all trials. Four raters, all PFMT experts, assessed a mutually exclusive subgroup of the trials. In addition to rating sufficiency - "Yes" compared to No" or "Uncertain" - raters also reported on CERT utility. Expert ratings were used to determine the proportion of CERT items rated as sufficiently reported. Rater agreement was estimated using coefficient kappa and McNemar's test. RESULTS: The range of CERT items rated as sufficiently reported was 0 to 15 of 19 items, and the mean for both trial arms was 5.5. For agreement, 11 of 19 items had sufficient data to estimate coefficient kappa and only 3 of 11 had a kappa >0.4 (moderate agreement). From the 12 of 19 items for which McNemar's test could be performed, five had evidence that PFMT experts more often rated the reporting as sufficient than the non-expert. Raters reported the CERT template was comprehensive but not complete and needed contextualizing for PFMT. CONCLUSIONS: Completeness of reporting was poor for this example of a rehabilitation exercise intervention, and equally poor in both trial arms. Inter-rater agreement of completeness of reporting was also poor. Using a data extraction tool with poor rater-agreement may add unnecessary burden in a review. However, using a data extraction tool that enables assessment of intervention homogeneity has benefits in making decisions about which data to pool or not. CLINICAL REHABILITATION IMPACT: Researchers reporting clinical trials must pay more attention to completeness of rehabilitation exercise reporting.

Learning to eat intuitively: A qualitative exploration of the experience of mid-age women.

Qualitative studies examining women's experiences of learning to eat more intuitively are scarce. We aimed to explore the experience of learning intuitive eating among mid-age women (n = 11) who participated in a web-based intuitive eating programme. Motivation to learn intuitive eating, perceptions of the experience of attempting to eat more intuitively, and facilitators and barriers to intuitive eating were explored using inductive thematic analysis. Findings suggest that women were able to learn to eat more intuitively; however, they encountered social and environmental barriers, and the 'unconditional permission to eat' aspect of intuitive eating was experienced as the most challenging.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: a cochrane systematic review abridged republication.

BACKGROUND: Pelvic floor muscle training is the most commonly used physical therapy treatment for women with urinary incontinence. OBJECTIVES: To assess the effects of Pelvic floor muscle training for women with urinary incontinence in comparison to a control treatment and to summarize relevant economic findings. METHODS: Cochrane Incontinence Group Specialized Register (February 12, 2018). SELECTION CRITERIA: Randomized or quasi-randomized trials in women with stress, urgency or mixed urinary incontinence (symptoms, signs, or urodynamic). DATA COLLECTION AND ANALYSIS: Trials were independently assessed by at least two reviewers authors and subgrouped by urinary incontinence type. Quality of evidence was assessed by adopting the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS: The review included thirty-one trials involving 1817 women from 14 countries. Overall, trials were small to moderate size, and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration. Based on data available, we can be confident that Pelvic floor muscle training can cure or improve symptoms of stress and all other types of urinary incontinence. It may reduce the number of leakage episodes and the quantity of leakage, while improving reported symptoms and quality of life. Women were more satisfied with Pelvic floor muscle training, while those in control groups were more likely to seek further treatment. Long-term effectiveness and cost-effectiveness of Pelvic floor muscle training needs to be further researched. CONCLUSIONS: The addition of ten new trials did not change the essential findings of the earlier review, suggesting that Pelvic floor muscle training could be included in first-line conservative management of women with urinary incontinence.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.

BACKGROUND: Pelvic floor muscle training (PFMT) is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed urinary incontinence (MUI) and, less commonly, urgency urinary incontinence (UUI).This is an update of a Cochrane Review first published in 2001 and last updated in 2014. OBJECTIVES: To assess the effects of PFMT for women with urinary incontinence (UI) in comparison to no treatment, placebo or sham treatments, or other inactive control treatments; and summarise the findings of relevant economic evaluations. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register (searched 12 February 2018), which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings, and the reference lists of relevant articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials in women with SUI, UUI or MUI (based on symptoms, signs or urodynamics). One arm of the trial included PFMT. Another arm was a no treatment, placebo, sham or other inactive control treatment arm. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed trials for eligibility and risk of bias. We extracted and cross-checked data. A third review author resolved disagreements. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. We subgrouped trials by diagnosis of UI. We undertook formal meta-analysis when appropriate. MAIN RESULTS: The review included 31 trials (10 of which were new for this update) involving 1817 women from 14 countries. Overall, trials were of small-to-moderate size, with follow-ups generally less than 12 months and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration, study populations and outcome measures. There was only one study of women with MUI and only one study with UUI alone, with no data on cure, cure or improvement, or number of episodes of UI for these subgroups.Symptomatic cure of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were eight times more likely to report cure (56% versus 6%; risk ratio (RR) 8.38, 95% confidence interval (CI) 3.68 to 19.07; 4 trials, 165 women; high-quality evidence). For women with any type of UI, PFMT groups were five times more likely to report cure (35% versus 6%; RR 5.34, 95% CI 2.78 to 10.26; 3 trials, 290 women; moderate-quality evidence).Symptomatic cure or improvement of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were six times more likely to report cure or improvement (74% versus 11%; RR 6.33, 95% CI 3.88 to 10.33; 3 trials, 242 women; moderate-quality evidence). For women with any type of UI, PFMT groups were two times more likely to report cure or improvement than women in the control groups (67% versus 29%; RR 2.39, 95% CI 1.64 to 3.47; 2 trials, 166 women; moderate-quality evidence).UI-specific symptoms and quality of life (QoL) at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT group were more likely to report significant improvement in UI symptoms (7 trials, 376 women; moderate-quality evidence), and to report significant improvement in UI QoL (6 trials, 348 women; low-quality evidence). For any type of UI, women in the PFMT group were more likely to report significant improvement in UI symptoms (1 trial, 121 women; moderate-quality evidence) and to report significant improvement in UI QoL (4 trials, 258 women; moderate-quality evidence). Finally, for women with mixed UI treated with PFMT, there was one small trial (12 women) reporting better QoL.Leakage episodes in 24 hours at the end of treatment: PFMT reduced leakage episodes by one in women with SUI (mean difference (MD) 1.23 lower, 95% CI 1.78 lower to 0.68 lower; 7 trials, 432 women; moderate-quality evidence) and in women with all types of UI (MD 1.00 lower, 95% CI 1.37 lower to 0.64 lower; 4 trials, 349 women; moderate-quality evidence).Leakage on short clinic-based pad tests at the end of treatment: women with SUI in the PFMT groups lost significantly less urine in short (up to one hour) pad tests. The comparison showed considerable heterogeneity but the findings still favoured PFMT when using a random-effects model (MD 9.71 g lower, 95% CI 18.92 lower to 0.50 lower; 4 trials, 185 women; moderate-quality evidence). For women with all types of UI, PFMT groups also reported less urine loss on short pad tests than controls (MD 3.72 g lower, 95% CI 5.46 lower to 1.98 lower; 2 trials, 146 women; moderate-quality evidence).Women in the PFMT group were also more satisfied with treatment and their sexual outcomes were better. Adverse events were rare and, in the two trials that did report any, they were minor. The findings of the review were largely supported by the 'Summary of findings' tables, but most of the evidence was downgraded to moderate on methodological grounds. The exception was 'participant-perceived cure' in women with SUI, which was rated as high quality. AUTHORS' CONCLUSIONS: Based on the data available, we can be confident that PFMT can cure or improve symptoms of SUI and all other types of UI. It may reduce the number of leakage episodes, the quantity of leakage on the short pad tests in the clinic and symptoms on UI-specific symptom questionnaires. The authors of the one economic evaluation identified for the Brief Economic Commentary reported that the cost-effectiveness of PFMT looks promising. The findings of the review suggest that PFMT could be included in first-line conservative management programmes for women with UI. The long-term effectiveness and cost-effectiveness of PFMT needs to be further researched.

Untangling chronic pain and post-concussion symptoms: the significance of depression.

OBJECTIVES: Post-concussion-like symptoms (PCS) are common in patients without a history of brain injury, such as those with chronic pain (CP). This exploratory study examined neuro-cognitive and psychological functioning in patients with PCS following mild traumatic brain injury (mTBI) or CP, to assess unique and overlapping phenomenology. METHODS: In this case-control study, participants (n = 102) with chronic symptoms after mTBI (n = 45) were matched with mTBI recovered (n = 31) and CP groups (n = 26), on age, gender, ethnicity and education. Psychological status, cognitive functioning, health symptoms, beliefs and behaviours were examined. RESULTS: Participants who had not recovered from an mTBI and participants with CP did not differ in terms of PCS symptoms, quality of life, distress or illness behaviours, however, the CP group endorsed fewer subjective cognitive problems, more negative expectations about recovery and more distress (p < 0.05). On cognitive testing participants who had not recovered from an mTBI demonstrated greater difficulties with attention (p < 0.01) although differences disappeared when depression was controlled in the analyses. CONCLUSIONS: Unique patterns associated with each condition were evident though caution is required in attributing PCS and cognitive symptoms to a brain injury in people with mTBI presenting with chronic pain and/or depression. Psychological constructs such as illness and recovery beliefs appear to be important to consider in the development of treatment interventions.

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women.

BACKGROUND: About one-third of women have urinary incontinence and up to one-tenth have faecal incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both prevention and treatment of incontinence.This is an update of a review previously published in 2012. OBJECTIVES: To determine the effectiveness of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and faecal incontinence in pregnant or postnatal women. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register (16 February 2017) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. DATA COLLECTION AND ANALYSIS: Review authors independently assessed trials for inclusion and risk of bias. We extracted data and checked them for accuracy. Populations included: women who were continent (PFMT for prevention), women who were incontinent (PFMT for treatment) at randomisation and a mixed population of women who were one or the other (PFMT for prevention or treatment). We assessed quality of evidence using the GRADE approach. MAIN RESULTS: The review included 38 trials (17 of which were new for this update) involving 9892 women from 20 countries. Overall, trials were small to moderate sized, and the PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful effects of PFMT.Prevention of urinary incontinence: compared with usual care, continent pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low-quality evidence). Similarly, antenatal PFMT decreased the risk of urinary incontinence in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; moderate-quality evidence). There was insufficient information available for the late (more than six to 12 months') postnatal period to determine effects at this time point.Treatment of urinary incontinence: it is uncertain whether antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low-quality evidence). This uncertainty extends into the mid- (RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; very low-quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; very low-quality evidence) postnatal periods. In postnatal women with persistent urinary incontinence, it was unclear whether PFMT reduced urinary incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; very low-quality evidence).Mixed prevention and treatment approach to urinary incontinence: antenatal PFMT in women with or without urinary incontinence (mixed population) may decrease urinary incontinence risk in late pregnancy (26% less; RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low-quality evidence) and the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low-quality evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low-quality evidence). For PFMT begun after delivery, there was considerable uncertainty about the effect on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; very low-quality evidence).Faecal incontinence: six trials reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low-quality evidence). In women with or without faecal incontinence (mixed population), antenatal PFMT led to little or no difference in the prevalence of faecal incontinence in late pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate-quality evidence). For postnatal PFMT in a mixed population, there was considerable uncertainty about the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, very low-quality evidence).There was little evidence about effects on urinary or faecal incontinence beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. We found no data on health economics outcomes. AUTHORS' CONCLUSIONS: Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women.It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women. Hypothetically, for instance, women with a high body mass index are at risk factor for urinary incontinence. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups and how much PFMT women in both groups do, to increase understanding of what works and for whom.Few data exist on faecal incontinence or costs and it is important that both are included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence.

Is Pelvic-Floor Muscle Training a Physical Therapy or a Behavioral Therapy? A Call to Name and Report the Physical, Cognitive, and Behavioral Elements.

This perspective article explores whether pelvic-floor muscle training (PFMT) for the management of female urinary incontinence and prolapse is a physical therapy or a behavioral therapy. The primary aim is to demonstrate that it is both. A secondary aim is to show that the plethora of terms used for PFMT is potentially confusing and that current terminology inadequately represents the full intent, content, and delivery of this complex intervention. While physical therapists may be familiar with exercise terms, the details are often incompletely reported; furthermore, physical therapists are less familiar with the terminology used in accurately representing cognitive and behavioral therapy interventions, which results in these elements being even less well reported. Thus, an additional aim is to provide greater clarity in the terminology used in the reporting of PFMT interventions, specifically, descriptions of the exercise and behavioral elements. First, PFMT is described as a physical therapy and as an exercise therapy informed predominantly by the discipline of physical therapy. However, effective implementation requires use of the cognitive and behavioral perspectives of the discipline of psychology. Second, the theoretical underpinning of the psychology-informed elements of PFMT is summarized. Third, to address some identified limitations and confusion in current terminology and reporting, recommendations for ways in which physical therapists can incorporate the psychology-informed elements of PFMT alongside the more familiar exercise therapy-informed elements are made. Fourth, an example of how both elements can be described and reported in a PFMT intervention is provided. In summary, this perspective explores the underlying concepts of PFMT to demonstrate that it is both a physical intervention and a behavioral intervention and that it can and should be described as such, and an example of the integration of these elements into clinical practice is provided.

Opportunities, challenges and concerns for the implementation and uptake of pelvic floor muscle assessment and exercises during the childbearing years: protocol for a critical interpretive synthesis.

BACKGROUND: Pregnancy and childbirth are important risk factors for urinary incontinence (UI) in women. Pelvic floor muscle exercises (PFME) are effective for prevention of UI. Guidelines for the management of UI recommend offering pelvic floor muscle training (PFMT) to women during their first pregnancy as a preventive strategy. The objective of this review is to understand the relationships between individual, professional, inter-professional and organisational opportunities, challenges and concerns that could be essential to maximise the impact of PFMT during childbearing years and to effect the required behaviour change. METHODS: Following systematic searches to identify sources for inclusion, we shall use a critical interpretive synthesis (CIS) approach to produce a conceptual model, mapping the relationships between individual, professional, inter-professional and organisational factors and the implementation, acceptability and uptake of PFME education, assessment and training during the childbearing years. Purposive sampling will be used to identify potentially relevant material relating to topics or areas of interest which emerge as the review progresses. A wide range of empirical and non-empirical sources will be eligible for inclusion to encompass the breadth of relevant individual, professional, inter-professional and organisational issues relating to PFME during childbearing years. Data analysis and synthesis will identify key themes, concepts, connections and relationships between these themes. Findings will be interpreted in relation to existing frameworks of implementation, attitudes and beliefs of individuals and behaviour change. We will collate examples to illustrate relationships expressed in the conceptual model and identify potential links between the model and drivers for change. DISCUSSION: The CIS review findings and resulting conceptual model will illustrate relationships between factors that might affect the implementation, acceptability and uptake of PFME education, assessment and training during the childbearing years. The model will inform the development and evaluation of a training package to support midwives with implementation and delivery of effective PFME during the antenatal period. The review forms part of the first phase of the United Kingdom National Institute for Health Research funded 'Antenatal Preventative Pelvic floor Exercises And Localisation (APPEAL)' programme (grant number: RP-PG-0514-20002) to prevent poor health linked to pregnancy and childbirth-related UI. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42016042792.