Adherence to behavioural interventions for urge incontinence when combined with drug therapy: adherence rates, barriers, and predictors.
To (i) investigate overall adherence to behavioural interventions (specifically, pelvic floor muscle (PFM) exercises), for women with urge-predominant urinary incontinence, and (ii) discuss perceived barriers to integrating and following the interventions, as reported by participants.
Data from a previous prospective two stage multi-centre randomised controlled clinical trial have been used. The study was designed to investigate the effect of drug therapy alone for women with urge urinary incontinence (UUI) compared to a combination of drug therapy and behavioural interventions over a 10-week period. The results from two self-administered exercise questionnaires (at 2, 4, 6 and 12 months) are discussed and reviewed with specific focus on PFM exercise adherence. After the initial 10-week intervention, the women did not meet with the clinicians or receive any additional exercise instruction.
Eighty-one percent of participants reported high rates of adherence to behavioural interventions (including the exercise regime) during the 10-week supervised period. This adherence continued during the 12-month follow up period but rates declined over the year; 64% of women reported that they continued to exercise two or more days per week at the twelve month follow up, but only 33% exercised five or more times per week. Finding time to exercise was the main barrier to exercise adherence. It was interesting to note that fewer than one in five women reported that the trial medication seemed more important than doing the exercises in the 10-week intervention phase.
Overall the results were similar to other studies regarding exercise adherence rates after a year. The only barrier significantly associated with decreased PFM exercise adherence was "difficulty finding time to do all the exercises". The authors suggest some ideas to promote adherence including associating exercise with other daily routines. Further research into methods and techniques to encourage and promote long-term exercise adherence is indicated.
Behavioural interventions including urge suppression strategies, delayed voiding and bladder retraining are widely recognised in managing UUI. There is, to date, no convincing evidence showing benefit from PFM training for over-active bladder (OAB) symptoms. However it is hypothesised that the use of PFM training for OAB may be beneficial in two instances; intentional contraction of PFM during urgency until the urge disappears, and strength training of PFM to change muscle physiology and thus stabilise neurogenic activity. (Bo et al 2007)
The current study is worth reading from the perspective of considering methods for conservative management of UUI and motivating patients to perform PFM training for both urinary urgency and urinary stress incontinence. Although this study was conducted by consultants involved in pharmaceutical research it offers some good points for those working in the clinical area of continence management and also in the broader settings of exercise prescription and adherence.
As physiotherapists, we are often confronted with the wider issue of maintenance of exercise programmes, and require strategies to encourage adherence and to minimise barriers. Clinicians working in the area of continence frequently hear patients reporting lack of time as a reason for not being able to do the prescribed programmes. Hence, this study confirms our experiences, and also describes several other reasons for poor adherence: lack of interest and/or discipline, and interference of exercises in daily life. It was interesting to note that "concern that exercises were not helping incontinence" was not associated with exercise adherence. The researchers suggest some possible solutions such as exercise reminders, group support, and regular monitoring. These issues have been discussed in previous work (Bo et al 2007) with the authors stressing the importance of evaluation, feedback and intensive guidance. Borello-France et al describe the initial 10-week phase as providing this type of intervention, which may have contributed to the high rate of PFM exercise compliance during this stage.
One suggestion to improve adherence is to integrate PFM exercise into community-based general fitness programmes (Brubaker et al 2008). However, it is important for women to have the skills to understand, and be able to contract their PFM effectively and functionally, before moving into a general exercise group. There is an inherent risk that incontinence may be affected adversely by incorrect techniques and valsalva maneuvers if women have no previous education in PFM function.
In conclusion, if we consider the above findings and suggestions for future practice, we need to ask:
* Do we have the resources to maintain follow up and/or use group work more than we currently are able?
* We know that there are recognised time frames for muscle rehabilitation, and fast twitch fibre recruitment, but should we be extending the intervention period?
* What are the best methods of limiting the barrier of "not enough time' and promoting adherence?
Clinically, the management of UUI or any presentation of incontinence relies on individualised assessment, competent PFM evaluation and a functional individual training programme to build strength, endurance and speed, and the co-ordination of the PFM in different situations (Neumann 2008). Regular follow up, and ongoing motivation are necessary to achieve positive outcomes and long term improvement. One of the limitations of behavioural interventions is that they rely on active patient participation. Motivating the patient to adhere to recommendations and to sustain her efforts over time is central to successful outcomes. A clinical tool that may enhance our interventions is motivational interviewing, which is recognised as being a useful technique to motivate behaviour change and compliance. As physiotherapists, understanding and applying this technique may be advantageous when working with individuals, and complementary to "exercise prescription".
Linley Edmeades NZRP
Dip Phty, PG Cert Continence Management
MNZCP (Continence and Women's Health)
Bo K Berghmans B, Morkved S, Van Kampen M (Eds) (2007): Evidence-based Physical Therapy for the Pelvic Floor. Bridging Science and Clinical Practice" Edinburgh London: Churchill Livingstone Elsevier, pp. 133-144; 218-222.
Brubaker L, Shott S, Tomezsko J, Goldberg RP (2008): Pelvic floor fitness using lay instructors. Obstetrics and Gynecology. 111: 1298-1304.
Neumann P, Morrison S (2008): Physiotherapy for urinary incontinence. Australian Family Physician 37: 118-121.
Borello-France D, Burgio KL, Goode PS, Markland AD, Kenton K, Blalsubramanyam A, Stoddard AM (2010): Adherence to behavioural interventions for urge incontinence when combined with drug therapy: Adherence rates, barriers, and predictors. Physical Therapy 90: 1493-1509. (Abstract prepared by Linley Edmeades).
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|Title Annotation:||CLINICALLY APPLICABLE PAPERS|
|Publication:||New Zealand Journal of Physiotherapy|
|Date:||Mar 1, 2011|
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