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

Geographic accessibility to physiotherapy care in Aotearoa New Zealand

Disparities in care access for health conditions where physiotherapy can play a major role are abetting health inequities. Spatial analyses can contribute to illuminating inequities in health yet the geographic accessibility to physiotherapy care across New Zealand has not been examined. This population-based study evaluated the accessibility of the New Zealand physiotherapy workforce relative to the population at a local scale. The locations of 5,582 physiotherapists were geocoded and integrated with 2018 Census data to generate 'accessibility scores' for each Statistical Area 2 using the newer 3-step floating catchment area method. For examining the spatial distribution and mapping, accessibility scores were categorized into seven levels, centered around 0.5 SD above and below the mean. New Zealand has an above-average physiotherapy-to-population ratio compared with other OECD countries; however, this workforce is maldistributed. This study identified areas (and locations) where geographic accessibility to physiotherapy care is relatively low.

Can We Improve the Technique of Pelvic Floor Muscle Exercises in Postmenopausal Women Using a Single Electromyography Biofeedback Session? An Experimental Study

Background: The aim of this study was to assess the effect of a single session of EMG biofeedback in a group of postmenopausal women on improving technique in pelvic floor muscle (PFM) contractions (exercises). Methods: Sixty-two women aged 60 to 85 years (69 ± 4; mean ± SD) participated in the study. We assessed the technique of PFM exercises via surface electromyography (EMG) using a vaginal probe. A single assessment sequence consisted of 11 exercises involving the conscious contraction of the PFM, during which the order of activation for selected muscles was determined. We then awarded scores for exercise technique on a scale from 0 to 4, where 4 represented the best technique and 0 represented no activation of PFMs. In the second assessment, we used a biofeedback method to teach PFM exercise technique. Results: In total, 32% (n = 20) of the participants were unable to correctly perform the first PFM contraction, scoring 0.9 ± 0.79. After a single EMG biofeedback session, these women received 1.7 ± 1.08 scores (p = 0.003). In the tenth exercise, there was also a statistically significant improvement between the first (baseline) and second assessment (1.7 ± 1.34 and 2.15 ± 1.09, respectively; p = 0.037). For the remaining exercises, the results were not statistically significant, but we observed a positive trend of change. Conclusions: The use of a single EMG biofeedback session is an effective method of improving technique in PFM exercises in a group of women who initially performed them incorrectly.

Efficacy of Warm Acupuncture Therapy Combined with Kegel Exercise on Postpartum Pelvic Floor Dysfunction in Women

INTRODUCTION AND HYPOTHESIS

The objective was to observe the clinical efficacy of warm acupuncture combined with Kegel exercise in treating postpartum pelvic floor dysfunction in women.

METHODS

A total of 70 primiparous women with postpartum pelvic floor muscle (PFM) injury were randomly divided into a combination group (n = 35, receiving warm acupuncture at Zhibian (BL54) acupoint and Kegel exercise) and a sham control group (n = 35, receiving sham warm acupuncture and Kegel exercise). Both groups were treated three times a week for 4 consecutive weeks. The recovery of PFM strength and changes in Urethral Rotation Angle (URA), Bladder Neck Descent (BND), and Retrovesical Angle (RVA) in pelvic floor ultrasound reports, the scores of pelvic floor dysfunction-related questionnaires, and the efficacy of urinary incontinence treatment of the two groups were compared before and after treatment.

RESULTS

After treatment, the recovery rates of type I and II PFM strength, pelvic floor ultrasound parameters, pelvic floor dysfunction-related scale scores, and urinary incontinence treatment efficacy in the combination group were significantly better than those in the sham control group (p < 0.05).

CONCLUSION

Warm acupuncture combined with Kegel exercise can significantly improve PFM strength and promote the recovery of postpartum pelvic floor function in women.

Current opinion: postpartum urinary disorders

PURPOSE OF REVIEW

The aim of this study was to describe the common postpartum urinary sequelae including urinary retention and incontinence, and to summarize the management of these conditions.

RECENT FINDINGS

Despite the high frequency of urinary disorders in obstetrics, screening and management protocols are rarely utilized by providers. Large variation exists in the literature regarding assessment of postpartum urinary retention, values of postvoid residuals and management of indwelling catheters in the immediate postpartum population. Recent expert guidance outlines a strategy for managing this condition.Research also highlights that screening for peripartum urinary incontinence is not a routine practice. The diagnosis is made more challenging by the fact that patients commonly understate and over-normalize their symptoms. Emerging studies have found that pelvic floor muscle training is cost-effective, preventive, and may improve symptoms in the postpartum setting.

SUMMARY

Increased awareness of urinary disorders in pregnancy and postpartum is imperative for appropriate diagnosis and management. Instituting standardized voiding protocols postpartum will allow providers to avoid undiagnosed postpartum urinary retention and its repercussions. Improved screening and education regarding urinary incontinence in the peripartum is important for early management, such as pelvic floor muscle training, and improved quality of life.

Effect of a Mobile App-Based Urinary Incontinence Self-Management Intervention Among Pregnant Women in China: Pragmatic Randomized Controlled Trial

BACKGROUND

Urinary incontinence (UI) is a highly prevalent health concern commonly observed during and after pregnancy that can substantially impact women's physical and psychological well-being and quality of life. Owing to its numerous advantages, mobile health may be a promising solution; however, it is unclear whether the app-based intervention can effectively improve UI symptoms during and after pregnancy.

OBJECTIVE

This study aimed to evaluate the effectiveness of the Urinary Incontinence for Women (UIW) app-based intervention for UI symptom improvement among pregnant women in China.

METHODS

Singleton pregnant women without incontinence before pregnancy who were aged ≥18 years and between 24 and 28 weeks of gestation were recruited from a tertiary public hospital in China and were randomly allocated (1:1) to either an experimental group (n=63) or a control group (n=63). The experimental group received the UIW app intervention and oral pelvic floor muscle training (PFMT) instructions, whereas the control group received oral PFMT instructions alone. Neither the participants nor the researchers were blinded to the intervention. The primary outcome was UI severity. The secondary outcomes included quality of life, self-efficacy with PFMT, and knowledge of UI. All data were collected at baseline, 2 months after randomization, and 6 weeks post partum through electronic questionnaires or by checking the electronic medical record system. Data analysis followed the intention-to-treat principle. A linear mixed model was used to examine the intervention effect on primary and secondary outcomes.

RESULTS

Participants in the experimental and control groups were comparable at baseline. Of the 126 overall participants, 117 (92.9%) and 103 (81.7%) women completed follow-up visits at 2 months after randomization and 6 weeks after delivery, respectively. A statistically significant difference in UI symptom severity was observed between the experimental group and control group (2 months after randomization: mean difference -2.86, 95% CI -4.09 to -1.64, P<.001; 6 weeks post partum: mean difference -2.68, 95% CI -3.87 to -1.49, P<.001). For the secondary outcomes, a statistically significant intervention effect on the quality of life, self-efficacy, and UI knowledge was found at the 2-month follow-up (all P<.05) and 6 weeks post partum (all P<.001).

CONCLUSIONS

The app-based UI self-management intervention (UIW) effectively improved UI symptom severity, quality of life, self-efficacy with PFMT, and knowledge of UI during the late pregnancy and early postnatal periods. Larger multicenter studies with a longer postpartum follow-up are required to further extend these findings.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800016171; http://www.chictr.org.cn/showproj.aspx?proj=27455.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/22771.

Barriers and enablers of pelvic floor rehabilitation behaviours in pregnant women with stress urinary incontinence: a qualitative analysis using the theoretical domains framework

BACKGROUND

Stress urinary incontinence during pregnancy is closely related to the occurrence of postpartum and long-term urinary incontinence. Early pelvic floor management is of great significance in promoting the recovery of pelvic floor tissues in pregnant women. However, effective management of urinary incontinence is far from achievable owing to the low adherence of pregnant women in partaking in pelvic floor rehabilitation. As a comprehensive framework for behavioural theory, the Theoretical Domain Framework allows for comprehensive identification of behavioural determinants. Using Theoretical Domain Framework, this study aimed to identify barriers and enablers of pelvic floor rehabilitation behaviours in pregnant women with stress urinary incontinence.

METHODS

A descriptive, qualitative design was used in this study. Face-to-face semi-structured interviews were conducted with pregnant women with stress urinary incontinence based on the Theoretical Domain Framework. The data were analysed using a combination of inductive and deductive methods.

RESULTS

Twenty pregnant women with stress urinary incontinence were interviewed. Seven themes were summarised and used to explain the pelvic floor rehabilitation behaviours of pregnant women with stress urinary incontinence. The seven themes were (1) individual knowledge and experience of pelvic floor management, (2) judgments about expected outcomes, (3) interactions of interpersonal situations, (4) environment, resources, and decision-making processes, (5) personal goal-setting and efforts towards behaviour change, (6) emotional influences on decision-making, and (7) personal characteristics. Besides the "Optimism" domain, 13 of the 14 Theoretical Domains Framework domains were found to influence pregnant patients' pelvic floor rehabilitation behaviours after deductive mapping of themes to the Theoretical Domains Framework. In addition, the inductive analysis generated a theme of personal characteristics that did not map to any of the Theoretical Domains Framework domains.

CONCLUSIONS

The pelvic floor rehabilitation behaviours of pregnant women with stress urinary incontinence are complex and are affected by many factors. The findings confirm the need for multiple interventions to support pelvic floor management in pregnant women with stress urinary incontinence, focusing on enhancing knowledge and skills in pelvic floor care and using appropriate behaviour change techniques (such as prompts) to provide a supportive environment.

Pelvic floor muscle training as a method of prevention and treatment of pelvic floor dysfunction and genital prolapse

Relevance. Pelvic floor dysfunction and pelvic organ prolapse are a significant problem today - even the initial manifestations of pelvic floor dysfunction can lead to reduced quality of sexual life, decreased activity, and then to social isolation and decreased self-esteem of women. Due to the growth of general life expectancy, the incidence rate is also increasing. One of the most popular conservative treatments for pelvic floor dysfunction is pelvic floor muscle training. The aim of this literature review is to consolidate the scattered information about the effectiveness of pelvic floor muscle training as a prevention and treatment of pelvic floor dysfunction. Materials and Methods. In writing the review, publications from the PubMed and Google Scholar databases from January 2019 were analyzed and systematized. Results and Discussion. Pelvic floor muscle training is one of the most prospective methods of non-invasive treatment for pelvic organ prolapse. It can take many forms and is represented by a range of different techniques: from the simple short-term muscle contraction and Kegel exercises to more complex and high-tech methods using electromyostimulation and biofeedback. However, timing of introduction and method for pelvic floor muscle training must be carefully considered in order to gain the maximum result. Conclusion. Based on the study, it can be concluded that the introduction of pelvic floor muscle training as part of prenatal care and in the antenatal period is the most appropriate way to prevent pelvic floor failure and genital prolapse. Further research is required to confirm the hypothesis.

Pelvic Floor Disorders and Pelvic Floor Muscle Exercise: A Survey on Knowledge, Attitude, and Practice among Pregnant Women in Northwest Ethiopia

The purpose of the study was to investigate 1: overall knowledge of pelvic organ prolapse (POP) and urinary incontinence (UI) as well as knowledge, attitudes, and practice of pelvic floor muscle exercise (PFME); and 2: the association of these factors with parity in pregnant women in Gondar, Ethiopia. A facility-based cross-sectional study was performed in the Central Gondar zone, northwest Ethiopia between February and April 2021. The associations between parity and knowledge of POP and UI, and knowledge, attitude, and practice towards PFME were estimated using logistics regression models and presented as crude and adjusted odds ratios with 95% confidence intervals. Nulliparous women were used as the reference. Adjustments were made for maternal age, antenatal care visits, and level of education. The study sample comprised 502 pregnant women: 133 nulliparous, and 369 multiparous. We found no association between parity and knowledge of POP, UI, or knowledge, attitude, and practice toward PFME. The sum score indicated poor knowledge about both POP, UI, and PFME in the study population, and poor attitude and practice of PFME. Despite a high attendance in antenatal care services, knowledge, attitude, and practice were poor, indicating a need for quality improvement of the services.

Opportunities and Capabilities to Perform Pelvic Floor Muscle Training Are Critical for Participation: A Systematic Review and Qualitative Meta-Synthesis

OBJECTIVE

Pelvic floor muscle training (PFMT) is considered a behavioral task that requires the interaction of physical, social, and cognitive processes. Enablers and barriers to participation in PFMT have been explored primarily in women. This review aimed to identify the barriers and enablers that influence participation in PFMT in all adult populations.

METHODS

A systematic review and meta-synthesis of qualitative literature was conducted. The inclusion criteria comprised qualitative studies with populations of people aged 18 years and older who have been recommended for PFMT. Line-by-line coding and an inductive thematic analysis identified themes that were applied to the Theoretical Domains Framework and Capabilities, Opportunities, and Motivation Behavioral Model to determine behavioral influences on PFMT.

RESULTS

Twenty full-text articles met inclusion criteria. PFMT was mostly influenced by individual opportunities impacted by social determinants and competing demands. Capability of carrying out PFMT was impacted by knowledge, understanding, and appropriate skill acquisition linked to self-efficacy.

CONCLUSION

Increasing opportunities and capabilities for engagement in PFMT are the most important factors in optimizing positive behavior changes. Ways to address these factors include clear patient communication to boost confidence in skill acquisition and using technology to encourage autonomy and improve convenience. Future research should address the impact of health professionals' beliefs about patient participation, assess the role of social values and gender roles, and explore the timing of the implementation of behavioral change strategies to improve PFMT.

IMPACT

This is believed to be the first systematic review and qualitative meta-synthesis to consider the enablers and barriers to participation in PFMT for all adult populations, purposes, and symptom complexes. Patient opportunities and capabilities are the greatest influencers on participation and self-efficacy. Individualized treatment approaches that acknowledge and address social influencers and competing demands will optimize self-efficacy and participation.

LAY SUMMARY

If you have pelvic floor muscle dysfunction, your opportunities and capabilities are the greatest influencers on participation and self-efficacy in PFMT. Your physical therapist can design individualized treatment approaches that acknowledge and address social influencers and competing demands to help you optimize participation.

Trajectories of Postpartum Recovery: What is Known and Not Known

Women's postpartum health is a public health issue that has lifelong consequences. Timely recognition and treatment of physical and mental health issues can have positive health consequences while lack of access to effective treatments or health care services can lead to long-term health problems. To advance knowledge of priority health symptoms and trajectories of postpartum recovery from women's health perspectives, we share findings from the Maternal health And Maternal Morbidity in Ireland (MAMMI) study. Data from 3047 first-time mothers recruited to a longitudinal maternal health study in Ireland from 2012 to 2017 reveal the trajectories of maternal health and health problems experienced up to 12 months postpartum. Morbidities explored include urinary incontinence, pelvic girdle pain, and sexual and mental health issues. Viewed together, and over time, the scale and persistent nature of many physical and mental health problems become apparent, yet considerable proportions of women were not asked directly about health problems by health care professionals. When women do not know what is and is not normal postpartum, they may suffer in silence and the consequence is that health problems/issues that are preventable, and treatable, are likely to become chronic. To make positive contributions to women's health, maternity care systems must be truly woman-centered and structured in ways that place emphasis on women's own health needs. In systems where women's voices and concerns are acknowledged and central, women are likely to thrive and flourish in motherhood.

Persuasive Technology in an mHealth App Designed for Pelvic Floor Muscle Training Among Women: Systematic Review

Background

Pelvic floor muscle training (PFMT) is one of the first-line treatments for stress urinary incontinence among pregnant women. Mobile health (mHealth) technology is potentially effective for delivering PFMT to pregnant women. Persuasive technology in the development of such mobile apps may facilitate behavior change by improving adherence to the exercises. The Capability, Opportunity, and Motivation–Behavior (COM-B) model is potentially useful in selecting the appropriate interventions to be incorporated into the apps.

Objective

This review of mHealth apps for PFMT aims to describe the principles of persuasion used for each app and to propose mHealth app design features based on the COM-B model.

Methods

A systematic literature search was conducted to answer three main research questions: what are the available mHealth apps for PFMT in the published literature, what persuasive strategies were used in their studies how were they mapped to the COM-B model, and how effective were the selected persuasive strategies for PFMT adherence? We searched PubMed, CINAHL, Web of Science, Scopus, and local Malaysian databases such as MyCite and MyMedR for articles reporting mHealth apps used for the delivery of PFMT. We included original articles reporting experimental and cross-sectional studies, including pilot or feasibility trials. Systematic and narrative reviews were excluded. Narrative and thematic syntheses were conducted on the eligible articles based on the research questions. The Cochrane risk of bias tool and the Risk of Bias Assessment Tool for Non-randomized Studies were used to assess study bias.

Results

Of the 169 records from the initial search, 10 (5.9%) articles meeting the selection criteria were included in this review. There were 8 mHealth apps designed for the delivery of PFMT. The Tät, which used 3 categories of persuasive system design, improved PFMT adherence and was cost-effective. Only 1 app, the iBall app, used all categories of persuasive system design, by including social support such as "competition" in its design. The Diário Saúde app was the only app developed using operant conditioning. All apps incorporated Tailoring and Expertise as part of their PSD strategies. Only 3 apps, the Diário Saúde, Tät, and Pen Yi Kang demonstrated improved PFMT adherence.

Conclusions

Persuasive technology used in mobile apps may target desired behavior change more effectively. The persuasive system design can be mapped to the COM-B model to explain its effectiveness on behaviour change outcomes.

Feasibility and Usability of Kegel Exercise Pregnancy Training App (KEPT App) among Pregnant Women with Urinary Incontinence

Pelvic floor muscle training (PFMT) is crucial to improving urinary incontinence (UI). This study aimed to assess the Kegel Exercise Pregnancy Training (KEPT) app’s feasibility and usability. This is a subgroup analysis from a researcher-blinded, randomised controlled pilot feasibility study among pregnant women with UI. The Malay version of the mHealth App Usability Questionnaire (Interactive) evaluated the app’s usability. Ten pregnant women completed the study, with mean age (SD) of 28.9 years (3.1). The app’s feasibility was rated above average. The app was reported with usable in all domains, (1) system information arrangement (4.98/7.0), (2) usefulness (4.89/7.0) and (3) ease-of-use and satisfaction (5.03/7.0). Education level was negatively correlated with the app’s feasibility (r = −0.81, p < 0.001) and all domains of usability such as ease-of-use (r = −0.66, p = 0.01), system information (r = −0.81, p = 0.001) and usefulness (r = −0.81, p = 0.001). PFMT video was among the app features chosen to be helpful. This study demonstrates that the newly developed user-centred design KEPT app is feasible and usable. However, the future app should provide direct feedback about their exercise techniques to motivate PFMT adherence.

Preliminary Effectiveness of mHealth App-Based Pelvic Floor Muscle Training among Pregnant Women to Improve Their Exercise Adherence: A Pilot Randomised Control Trial

This pilot randomised control trial (RCT) aimed to evaluate the feasibility and preliminary effectiveness of conducting a full-powered trial for a newly developed pelvic floor muscle training (PFMT) app among pregnant women with urinary incontinence (UI) in Malaysia. This was a prospective, single-centre, single-blind, parallel, randomised controlled, pilot feasibility study—the Kegel Exercise Pregnancy Training app (KEPT app) trial. In total, 26 pregnant women with urinary incontinence from an urban healthcare clinic were recruited and randomly assigned to either intervention or waitlist control group. The intervention group received the KEPT app, while the control group received usual antenatal care (waitlist control). Of the 26 pregnant women, 16 (61.5%) completed the two-month follow-up. The recruitment rate was 54.2%, and the retention rate was 62.5% in the intervention group and 60% in the control group. There was a significant difference between intervention and control groups’ baseline measurement in the severity of UI (p = 0.031). The app improved their knowledge (p = 0.011) and self-efficacy (p = 0.038) after the first month and attitude (p = 0.034) after two months of intervention, compared with the control group. This study supports the feasibility of our future cluster RCT. The KEPT app demonstrates a promising effect in improving PFMT attitude and self-efficacy and potentially enhancing exercise adherence among pregnant women with UI. Trial registration: This study was prospectively registered on ClinicalTrials.gov on 19 February 2021 (NCT04762433).

Improving Pelvic Floor Muscle Training Adherence Among Pregnant Women: Validation Study

BACKGROUND

Mobile health apps, for example, the Tät, have been shown to be potentially effective in improving pelvic floor muscle training (PFMT) among women, but their effectiveness in pregnant women was limited. Adherence to daily PFMT will improve pelvic floor muscle strength leading to urinary incontinence (UI) improvement during the pregnancy.

OBJECTIVE

This study aims to document the validation process in developing the Kegel Exercise Pregnancy Training app, which was designed to improve the PFMT adherence among pregnant women.

METHODS

We utilized an intervention mapping approach incorporated within the mobile health development and evaluation framework. The framework involved the following steps: (1) conceptualization, (2) formative research, (3) pretesting, (4) pilot testing, (5) randomized controlled trial, and (6) qualitative research. The user-centered design-11 checklist was used to evaluate the user-centeredness properties of the app.

RESULTS

A cross-sectional study was conducted to better understand PFMT and UI among 440 pregnant women. The study reported a UI prevalence of 40.9% (180/440), with less than half having good PFMT practice despite their good knowledge. Five focus group discussions were conducted to understand the app design preferred by pregnant women. They agreed a more straightforward design should be used for better app usability. From these findings, a prototype was designed and developed accordingly, and the process conformed to the user-centered design-11 (UCD-11) checklist. A PFMT app was developed based on the mHealth development and evaluation framework model, emphasizing higher user involvement in the application design and development. The application was expected to improve its usability, acceptability, and ease of use.

CONCLUSIONS

The Kegel Exercise Pregnancy Training app was validated using a thorough design and development process to ensure its effectiveness in evaluating the usability of the final prototype in our future randomized control trial study.

Effect of birth ball abdominal core training on pregnancy fatigue, waist pain and delivery outcomes

OBJECTIVE

To evaluate the effect of birth ball abdominal core training on fatigue, waist pain, and delivery outcomes in middle and late pregnancy.

METHODS

A prospective study of 209 primipara in total with 24-27 weeks of gestation were recruited and divided into the training group (109 cases) and the control group (100 cases). The control group received routine prenatal exercise. On the basis of routine prenatal exercise, pregnant women in the training group were given birth ball exercises based on abdominal core training. The difference in pregnancy fatigue, waist discomfort, and delivery outcomes between the two groups were compared.

RESULTS

The waist pain and fatigue ratings of women were significantly lower and the vaginal delivery rate (74.3%) was significantly higher (62%) (P < 0.001) in the training group. There were no significant differences in the total stage of labor, postpartum hemorrhage, neonatal weight and 1-min neonatal Apgar score between the two groups. The rate of episiotomy in the training group (14.7%) was significantly lower than that in the control group (25.0%) (P < 0.05).

CONCLUSION

Birth ball exercises can relieve fatigue and waist pain in middle and late 2021 pregnancy, reduce the rate of episiotomy, and promote spontaneous vaginal delivery.