Treat urinary incontinence remotely Treat urinary incontinence remotely References

Urinary incontinence, defined as any involuntary loss of urine[1], affects up to 1 in 3 women over the age of 65[2]. In addition, up to 25% of affected women present symptoms qualified as severe, with 10 leaks or more per week[3]. If left untreated, urinary incontinence can lead to urinary tract infections, skin irritations and ulcers[4]. On the psychosocial side, it also has negative consequences on self-esteem, sex life, well-being and quality of life. In older women, it also leads to a decrease in physical activity and social participation, as well as an increase in isolation and the risk of admission to a residential center[5]. The taboo and stigma surrounding urinary incontinence lead affected women to reduce their outings and social contacts as well as to feel a lot of shame related to their condition[6].

Pelvic floor muscle exercises are the officially recommended first-line treatment, both in Canada and internationally, for urinary incontinence[7]. These strengthening exercises can be taught and performed during pelvic floor physiotherapy treatments.

Telerehabilitation

The pandemic has amplified some barriers to pelvic floor physiotherapy that were already present. Prior to the outbreak of COVID-19, lack of information was most often the reason for not consulting. Indeed, many women did not raise the issue with a health professional, out of embarrassment or because of the belief that urinary leakage is inevitable with advancing age[8]. There could also be added certain financial constraints in access to treatment[9]or the lack of physiotherapists trained in pelvic floor rehabilitation, which generated long waiting lists[10]. However, from the start of the coronavirus crisis, a new major barrier appeared: the concern linked to in-person attendance at healthcare settings. This concern, which particularly affected the elderly clientele, even led to a drop of up to 80% in certain consultations[11]. During the first confinement in the spring of 2020, physiotherapy clinics had to close their doors to the general population for more than three months[12], which further limited access to treatment.

During this pandemic period, physiotherapists have had to adapt their practice in order to reduce contact and avoid the spread of the coronavirus[13], in particular by adopting a shift towards telerehabilitation[14]. From March to June 2020, physiotherapists in Quebec carried out more than 350,000 remote consultations[15]. Receiving health care remotely is therefore now possible on a large scale in Quebec and seems to have the favor of the public, with a satisfaction rate of 91% among patients for medical consultations during the pandemic[16]. In the long term, virtual care could lead to savings for the healthcare system and perhaps also increase the speed of access to services[17].

Telerehabilitation, or remote delivery of physiotherapy care using technological tools that provide virtual consultations in real time, could be an option for providing pelvic floor physiotherapy. A large part of physiotherapy practice is based on educating patients about their condition, the exercises needed to manage them, and the lifestyle changes to adopt in order to reduce or adequately manage symptoms. All of these elements of care do not require direct contact. Pelvic floor physiotherapy treatments often follow a similar structure. A mainly remote approach would respond to the desire to limit contact with healthcare settings. Due to its intimate nature, pelvic floor physiotherapy nevertheless poses some specific challenges compared to more general physiotherapy.

A new program

In an attempt to respond more adequately to current needs, the laboratory team of the Canada Research Chair in Urogynecological Health and Aging, Professor Chantal Dumoulin, of the Université de Montréal, has developed a hybrid treatment that combines approach in person and remotely. Adapted from the GROUP program for the treatment of urinary incontinence in elderly women[18], this telerehabilitation project includes an in-person assessment meeting as well as a 12-week follow-up by videoconference. During the 12 weeks of remote treatment by telerehabilitation, the women in the program attend a weekly session by videoconference. A physiotherapist leads this session, which includes educational capsules and exercises as well as explanations for exercises at home. A large clinical trial that brought together more than 360 women across Quebec recently validated the face-to-face version of the program[19]. This program included the same 12 sessions, followed the same weekly progression for the exercises and covered the same themes in the educational capsules as its telerehabilitation version.

Few initiatives of this kind have yet been tried around the world. Studies on the subject are still preliminary and report results on a very limited number of people (three subjects)[20]. Still others are evaluating asynchronous options, for example with email contact or treatment using exercise machines, and are therefore further from the definition of telerehabilitation[21]. Over the next few months, the research team from the University of Montreal will therefore assess whether such an online program is feasible and well received. Its results will determine the effectiveness of this form of telerehabilitation initially implemented as a temporary solution to confinement announced as temporary. In addition to validating the clinical effectiveness of the videoconferencing approach, the study will collect testimonials from participants in the program to issue recommendations and support the implementation of this type of service across Quebec.

Limits

However, certain specific clinical acts related to touch lend themselves less to remote approaches[22]. During an in-person consultation, the physiotherapist begins with an assessment of the different structures involved[23]. The pelvic floor includes all the different tissues that close the pelvis and surround the genitals, including the connective tissues that support the organs, ligaments and muscles. It is especially the muscles that are solicited during the treatment of urinary incontinence. The muscles of the pelvic floor are thus precisely evaluated according to several criteria including strength, endurance and coordination. During this assessment, the physiotherapist ensures that the patient performs the desired contraction for the exercises, either a contraction that leads to an elevation or an inward suction. Learning which contraction to perform is a crucial step in the treatment. Women who consult sometimes need more than one explanation (eg, "like zipping up a zipper," "like pushing a blueberry up their vagina," "like sucking a spaghetti," etc.) to arrive at the right contraction, in a process of trial and error. Even with the help of internal digital palpation, either inserting fingers into the vaginal cavity to guide contraction, or being guided by measuring devices to confirm or facilitate movement, the patient will generally have need more than a minute to reach the right contraction[24].

In fact, up to a quarter of women tend to reverse control when instructed to contract the pelvic floor muscles[25]. Pushing or pushing while holding your breath rather than performing a contraction (or lift or suction) is not without consequences, however. Pushing lowers the pelvic floor rather than raising it, causing the tissues to stretch[26]. If the patient performs the contraction repeatedly incorrectly, for example as part of an exercise program, this incorrect downward motion can damage the structures being treated. Like constipation, pregnancy and childbirth or chronic cough, such repeated stretching of pelvic structures, particularly nerve structures, is associated with weakening of the pelvic floor muscles[27]. An in-person assessment by a physiotherapist is therefore essential for the smooth running of the treatment, which explains why this step is found in the program proposed by the research team, and hence the hybrid aspect of this treatment.

The innovative project proposed by the research team from the Université de Montréal thus attempts to optimize the possibilities offered by telerehabilitation while respecting the realities inherent in this very specific practice of pelvic floor physiotherapy. Born out of confinement and physical distancing, the project could pave the way for a whole new category of care, in times of pandemic and beyond. In a post-COVID era, applications of such a program to a population that is rural or living in remote areas would certainly be welcomed.

—An article by Mélanie le Berre, student in the doctoral program in rehabilitation sciences at the Université de Montréal