Does self-motivation improve success rates in pelvic floor muscle training in women with urinary incontinence in a secondary care setting?

Vella M, Nellist E, Cardozo L, Mastoroudes H, Giarenis I, Duckett J.

Int Urogynecol J 2013. Published online: May 24, 2013

Ann Dunbar PT, DPT, MS, WCS

September 11, 2013

Primary Aim:  To determine the effect of women’s self-motivation to perform pelvic floor muscle training (PFMT) on outcome, assessing both pre- and post-treatment with PFMT

Subjects:  Women with stress-predominant UI were recruited from 3 urogynecology clinics.  Exclusion criteria included:  Urgency predominant mixed UI; pregnancy/breastfeeding; symptomatic prolapse; surgery for UI in past 6 months; hematuria; UTI; bladder or urethral pain; anticholinergic medication.

Study Design:  Correlational  

Methods:

·         At initial consultation, participants were asked to complete the Incontinence Treatment Motivation Questionnaire (ITMQ) (see Additional Reading section below, #1).

·         Participants completed a 24-h pad test and then completed 12-week course of PFMT

o   PFMT included 4 visits at 4 week intervals

o   Four specialist pelvic floor physiotherapists completed digital exam on first visit to assure women able to accurately contract PFM; strength grade given based on Oxford scale; treatment included home exercises of a minimum of 3 sets of 8 PFM contractions per day. Patients also taught “The knack.”

·         At end of 12-week study period, women completed a Patient Global Impression of Improvement (PGI-I) questionnaire and completed a second 24-hour pad test.

·         Spearman’s correlation coefficient used to assess correlation between PGI-I scores and the difference between initial and final pad test and the ITMQ.

Results

Subjects: 102 women were screened and 65 subjects with age range 24 to 76 (mean 50.5) completed the study. Mean parity was 2.   Women who had undergone previous PFM treatment was 83%; 18.5% were < 1yr earlier, 12.9% were 1 to 5 years earlier, > 68.6% earlier 5 years earlier.   PFM strength with Oxford Scale was 2.5 (range 0 to 4). At end of 12 weeks of intensive physiotherapy, 49% reported improvement, 43% reported no change in sx, and 8% reported deteriorating sx.

ITMQ Results: 3 of 5 domains (positive attitude to treatment, frustration of living with incontinence, and desire for treatment) significantly correlated with PGI-I outcome whereas 2 domains did not (excuses for not performing PFMT and severity of incontinence). See Table 3 for correlation of the PGI-I scores with ITQM results.

Pad Test:  Mean change in 24-hour pad test weight after 12 weeks was 6 g with range from a decrease of 47.7g to an increase in 33.9g (standard deviation was 20.8g). Those who reported improvement with PFMT (scored 1, 2, or 3 on their PGI-I) had mean improvement of 11.5g.

PFMT: regimen conformed to National Institute for Health and Clinical Excellence and consisted of 8 contractions 3x/day. Authors chose to use supervised rather than unsupervised exercises based on evidence so participants had direct contact.

Discussion

Results suggest positive attitude towards treatment and a desire for treatment were associated with better outcome following a supervised course of PFMT. Additionally, poorer outcome was associated with frustration of living with incontinence.  Results conclude self-motivation is necessary in order to determine improved success following PFMT.

·         Evidence in various areas of medicine suggests that motivational regulation may be associated with improved outcomes (other research demonstrated self-motivation improved COPD care workflows; motivational interviewing (see Clinical Application #4) helped improve medication compliance in pts with HTN).

·         ITMQ can be used to help predict which women will benefit from PFMT.

·         Authors suggest challenge for clinicians may be to find the ideal PFMT program and suggest clinicians’ focus on methods of enhancing client’s self motivation which would ensure better program adherence and better results.

Weaknesses:  Participants may be a select population since they were referred to secondary care and may be more motivated than average. Also, of the 102 women initially screened, 20 declined participation in PFMT and 14 were lost to follow up creating a bias (i.e. those that remained were more motivated).  If non-completers and those refusing PFMT were counted as failures, success rate for PFMT would drop from 49% to 32%.

Clinical Application

1) Are there changes in the methodology that you think would improve the participant’s outcome?

2) Authors state that “patients with lower motivation may best be treated with other forms of therapy.” Do you agree?

3) What strategies do you use in your practice to enhance patient self motivation?

4) From “A Matter of Motivation,” in August, 2013, PT in Motion magazine, discusses the use of motivational interviewing now being taught in first professional PT programs.   It is described as a behavior-change technique that requires “stepping out of that expert role….riding the bus with the patient,” not pushing nor pulling but moving along the journey together. This requires asking the right questions to identify barriers to change and creating strategies together to address the barriers.  In working with people with urinary incontinence, how do we do this, what information do we need to gather?

Additional Reading:

1)  Sarma S, Hawthorne G, Thakkar K, Hayes W, Moore KH: The development of an Incontinence Treatment Motivation Questionnaire for patients undergoing pelvic floor physiotherapy in the treatment of stress urinary incontinence. Int Urologynecol J. 2009; 20:1085-1093. 

Study whose aim was to design and validate a motivation questionnaire that would be used for future RCTs testing hypothesis that improving motivation might improve PFMT participation rates. Eight multidisciplinary continence advisors (Urogyn, Nurse Specialist, Pelvic floor PTs) developed 5 broad domains for semi-structured interviews. This free range interview format was then used to elicit responses from 16 consecutive women with SUI coming to UroGyn unit. Most common motivating issue was embarrassment caused by a bad experience. Second most common issue was women being “sick of the inconvenience caused to everyday activities.” Results of the item bank construction were as follows:

Dimension 1: Positive attitude towards treatment

·         Items in this section covered statements about women taking action toward their PFMT

Dimension 2: Excuses for not doing PFMT

·         Items in this section covered reasons cited by subjects why they felt unable to perform PFMT such as PFMT too difficult to fit into daily life, prospect of long-term adherence to program too daunting, muscles feel too weak.

Dimension 3: Living with urinary incontinence

·         Items in this section captured the frustration caused by incontinence

Dimension 4: Desire for treatment

·         Items in this section covered patient preference between surgery and supervised PFMT

Dimension 5: Incontinence severity affects PFMT

·         Items in this section addressed the relationship between motivation for PFMT and incontinence severity

2)  Hayhurst C: A matter of motivation. PT in Motion. 2013; August:18-24.