Prognostic indicators of poor short-term outcome of physiotherapy intervention in women with stress urinary incontinence

AIMS

To identify prognostic indicators independently associated with poor outcome of physiotherapy intervention in women with primary or recurrent stress urinary incontinence (stress UI).

METHODS

A prospective cohort study was performed in physiotherapy practices in primary care to identify prognostic indicators 12 weeks after initiation of physiotherapy intervention. Patients were referred by general practitioners or urogynecologists. Risk factors for stress UI were examined as potential prognostic indicators of poor outcome. The primary outcomes were defined as poor outcome on the binary Leakage Severity scale (LS scale) and the binary global perceived effectiveness (GPE) score.

RESULTS

Two hundred sixty-seven women, with a mean age of 47.7 (SD = 8.3), with stress UI for at least 6 months were included. At 12 weeks, 43% and 59% of the women were considered recovered on the binary LS scale and the binary GPE score, respectively. Prognostic indicators associated with poor outcome included 11 indicators based on the binary LS scale and 8 based on the binary GPE score. The prognostic indicators shared by both models show that poor recovery was associated with women with severe stress UI, POP-Q stage > II, poor outcome of physiotherapy intervention for a previous UI episode, prolonged second stage of labor, BMI > 30, high psychological distress, and poor physical health.

CONCLUSIONS

This study provides robust evidence of clinically meaningful prognostic indicators of poor short-term outcome. These findings need to be confirmed by replication studies.

Factorial validity and internal consistency of the PRAFAB questionnaire in women with stress urinary incontinence

Background

To investigate the factor structure, dimensionality and construct validity of the (5-item) PRAFAB questionnaire score in women with stress urinary incontinence (stress UI).

Methods

A cross validation study design was used in a cohort of 279 patients who were randomly divided into Sample A or B. Sample A was used for preliminary exploratory factor analyses with promax rotation. Sample B provided an independent sample for confirming the premeditated and proposed factor structure and item retention. Internal consistency, item-total and subscale correlations were determined to assess the dimensionality. Construct validity was assessed by comparing factor-based scale means by clinical characteristics based on known relationships.

Results

Factor analyses resulted in a two-factor structure or subscales: items related to 'leakage severity' (protection, amount and frequency) and items related to its 'perceived symptom impact' or consequences of stress UI on the patient's life (adjustment and body (or self) image). The patterns of the factor loadings were fairly identical for both study samples. The two constructed subscales demonstrated adequate internal consistency with Cronbach's alphas in a range of 0.78 and 0.84 respectively. Scale scores differed by clinical characteristics according to the expectations and supported the construct validity of the scales.

Conclusion

The findings suggest a two-factorial structure of the PRAFAB questionnaire. Furthermore the results confirmed the internal consistency and construct validity as demonstrated in our previous study. The best description of the factorial structure of the PRAFAB questionnaire was given by a two-factor solution, measuring the stress UI leakage severity items and the perceived symptom impact items. Future research will be necessary to replicate these findings in different settings, type of UI and non-white women and men.

The psychometric properties of the PRAFAB-questionnaire: a brief assessment questionnaire to evaluate severity of urinary incontinence in women

AIMS

To determine the psychometric properties of the (5-item) total PRAFAB-questionnaire score in a group of patients with stress or predominant urgency urinary incontinence (UI) to justify its use in clinical practice and research.

METHODS

Psychometric properties were assessed in a prospective cohort of patients with primary or recurrent UI referred for physiotherapy treatment.

RESULTS

In total, 99 women enrolled the cohort study, of whom 87 were classified as stable ("about the same" on the global rating scale [GRS]) and included for analyses. Factor analysis resulted in a single underlying factor in both UI groups. The PRAFAB-questionnaire scores demonstrated excellent test-retest reliability (high ICCsagreement [0.93-0.95] and kappa scores for individual items) and excellent internal consistency (Cronbach's alpha's of 0.82). The PRAFAB-questionnaire was able to discriminate among different patient groups indicating good construct validity. Responsiveness to clinical improvement for both groups was shown to be excellent with large effect size statistics and high correlations (0.79-0.89) with patients' perceived benefit on the GRS indicating excellent longitudinal validity. The minimally important change stratified for non-severe and severe classified patients were estimated between -2.5 to -4.6 and -4.5 to -7.0 points, respectively for the stress UI group and -2.5 to -3.4 points and -4.0 to -4.4, respectively for the urgency UI group.

CONCLUSIONS

The brief and simple PRAFAB-questionnaire demonstrated good psychometric properties for use in clinical practice and research to evaluate treatment effects for UI in women. Future research will be necessary to replicate these findings and further explore its psychometric properties.

Effectiveness of pelvic floor muscle exercise therapy supplemented with a health education program to promote long-term adherence among women with urinary incontinence

AIMS

A longitudinal randomized controlled trial (RCT) was conducted to evaluate the effectiveness of physiotherapeutic pelvic floor muscle exercise (PFME) therapy supplemented with a health education program to promote long-term adherence among women with stress, mixed, and urge urinary incontinence (UI).

METHODS

Women (n = 129) were evaluated by their general practitioner (GP) and randomized in either the control group (PFME therapy alone) or one of the three experimental groups (PFME therapy with one of the three health education program versions). Therapy consisted of 9-18 individual 30 min sessions with a specialized physiotherapist, over 14-22 weeks. Outcome measures were weekly frequency of wet episodes and adherence behavior. Women were assessed up to 1 year after therapy.

RESULTS

The health education program had no additional impact to individual contact during PFME therapy on treatment outcome, nor on adherence. However, the individual physiotherapeutic treatment protocol was very effective in reducing weekly frequency of wet episodes from 23 to 8 times a week immediately after therapy, and effects were maintained during the 1-year follow-up period. Adherence was very high; most women followed the behavioral advice on average 6 days/week at posttest and still 4-5 days 1 year after therapy. Results were not different between incontinence types. Women who had relatively frequent wet episodes before and 1 year after therapy had higher adherence levels compared to women who had fewer weekly losses.

CONCLUSIONS

Results suggest that a standardized protocol checklist for physiotherapists covering all treatment aspects of PFME therapy, may optimize long-term treatment outcome and adherence behavior among patients, and outshines the addition of a health education program.

Program development for promoting adherence during and after exercise therapy for urinary incontinence

This paper presents the development process of a health education program to promote adherence to a pelvic floor muscle exercise (PFME) therapy for women with urinary incontinence (UI). The development process started with a needs assessment phase in which the health problem, health-related quality of life, and behavioral and environmental determinants were assessed. Guided by the intervention mapping (IM) approach, program objectives were formulated and, on the basis of both empirical and theoretical data, intervention methods for influencing determinants of adherence to PFME therapy were chosen and translated into practical strategies. This information was assimilated to a transparent description of the program design. The theoretical rationale of the program was based on the transtheoretical model, the self-regulation theory and principles of targeted communication and sex-specific health care.