The development of a physical therapy service to treat urinary incontinence: Results of a RE-AIM evaluation
Brosina de Leon E, Cardoso MN, de Brito E, Dos Santos MM, Almeida FA. The development of a physical therapy service to treat urinary incontinence: Results of a RE-AIM evaluation. Front Glob Womens Health. 2022 Oct 25;3:1004140. doi: 10.3389/fgwh.2022.1004140. PMID: 36386433; PMCID: PMC9641086.Link to Original Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9641086/
Key Points
1. The study focused on the implementation and evaluation of a Pelvic Physical Therapy Service for older women with urinary incontinence (UI) using the RE-AIM framework.
2. The service enrolled 34 older women with UI symptoms and demonstrated significant improvements in pelvic floor muscle strength, power, endurance, and fast contraction capacity after the intervention.
3. However, there was a high dropout rate among participants, which may be attributed to factors such as mild symptoms, competing priorities, and fear or stigma related to pelvic exams.
4. Program implementation was supported by Physical Therapy teams, and the service has been maintained for over 4 years.
5. The findings suggest that conservative physiotherapy treatment is feasible and beneficial for UI patients, highlighting the need for specialized care and evidence-based interventions.
6. The study provides insights and strategies for the adoption, implementation, and maintenance of a Physical Therapy pelvic service, emphasizing the importance of individualized treatment and interinstitutional partnerships.
Introduction
Urinary incontinence (UI) is a common condition characterized by involuntary urine leakage, with stress UI being the most prevalent type. UI has substantial costs, with women spending a significant amount out of pocket for management and experiencing a decrement in quality of life. Prevalence of UI increases in women aged 70 years and older, and it primarily affects emotional wellbeing. Conservative management, particularly pelvic floor muscle training (PFMT), is recommended as the first-line treatment for UI due to its effectiveness and minimal risk. However, UI care, especially conservative treatment, is scarce in Brazil.
To address this gap, a Pelvic Physical Therapy service was established in Amazonas, Brazil in 2018 through an interinstitutional partnership. The service aims to provide specialized care for older women with UI. The study evaluates the development process of this service using the RE-AIM framework, which assesses the reach, effectiveness, adoption, implementation, and maintenance of health interventions.
In summary, UI is a prevalent condition with significant impacts on quality of life and costs. Conservative management, such as PFMT, should be the initial approach. However, UI care, particularly conservative treatment, is lacking in Brazil. The Pelvic Physical Therapy service in Amazonas aims to address this gap, and the study evaluates its development process using the RE-AIM framework.
Methods
Design
The research paper describes a pragmatic case study design that aims to evaluate the development process of a Pelvic Physical Therapy Service for older women with urinary incontinence (UI) in Amazonas, Brazil. The study collected data from August 2018 to December 2019 at FUnATI's Gerontological Polyclinic. The study protocol was approved by the Ethics Committee from Amazonas Federal University, and all methods were conducted in accordance with relevant guidelines and regulations.
The eligibility criteria for participants in the study included women who were 60 years of age or older and self-reported experiencing UI symptoms, such as Stress UI, Urge UI, or Mixed UI. Women with neurogenic bladder, gynecological or urinary tract infections, infectious diseases, pelvic organ prolapse grade above 2, or any comorbidities or risk factors that might compromise the treatment were excluded. The study also excluded women who refused physical examination or had three or more absences in their treatment from the effectiveness analysis.
Overall, the study design is focused on evaluating the resources committed to the Pelvic Physical Therapy Project and its impact on older women with UI. By following the structured assessment and utilizing the RE-AIM framework, this research aims to provide valuable insights into the development process and effectiveness of pelvic physical therapy for UI in older women in Amazonas, Brazil.
Intervention description
The research paper describes the development process of a Pelvic Physical Therapy Service for older women with urinary incontinence (UI) in Amazonas, Brazil. The intervention begins with an initial assessment that collects personal data, anthropometric and blood pressure measurements, and clinical information. Patients are then referred to Physical Therapy evaluation, where they undergo a health history tracking and a physical examination by a certified physical therapist. The evaluation includes assessing pelvic floor muscle strength, contractile components of the pelvic floor muscles, and measurement of urinary loss. Based on the evaluation, patients are assigned to either individual or group-based treatment.
Individual treatment consists of Pelvic floor muscle training (PFMT) and physical therapy follow-up, where patients learn how to contract the pelvic floor muscles correctly and perform exercises for strengthening and stretching. Group-based treatment follows the same PFMT regimen as individual treatment. Patients in both groups receive 10 intervention sessions, with additional sessions available depending on progress.
All patients are reassessed every 10 sessions, and if there is no significant improvement, additional sessions are provided. Patients are asked to provide feedback on their treatment experience after discharge.
Overall, the Pelvic Physical Therapy Service aims to improve UI symptoms in older women and increase service capacity to assist more patients.
The RE-AIM framework
The RE-AIM framework was used to evaluate the implementation of the Pelvic Physical Therapy Service for older women with urinary incontinence (UI) in Amazonas, Brazil. The framework consists of five elements: Reach, Effectiveness, Adoption, Implementation, and Maintenance.
Reach refers to the number, proportion, and representativeness of individuals willing to participate in the program. The participation rate and dropouts were assessed using data from the target population. Costs for recruitment and reaching the specific service were also included.
Effectiveness measures the impact of an intervention on important outcomes. In this study, it was evaluated by comparing results before and after the intervention using measures such as the AFA, PERFECT, and PAD TEST. Cost analysis was also considered.
Adoption at the organizational level is measured by the number and representativeness of environments and intervention agents involved. The study assessed the number of employees involved in implementing the service and the required professional skills.
Implementation refers to delivering the program as intended. It includes the frequency of contact, average number of sessions held, and the necessary resources. The study evaluated the physical space and material and human resources required for the services.
Maintenance focuses on the long-term sustainability of the program at both the configuration and individual levels. It involves ensuring the long-term benefits and institutionalization of the intervention. The study assessed the continuity of the program and its monthly maintenance costs.
Results
Reach
The Reach section of the research paper evaluated the development process of a Pelvic Physical Therapy Service for older women with urinary incontinence (UI) in Amazonas, Brazil. Out of 102 women with UI symptoms, 23.5% were excluded from the study. The participation rate was 74.5%, with 7 women declining the pelvic examination and 2 not meeting eligibility criteria.
The recruitment cost for the service was R$ 3,037.24, which included the salaries of the front desk clerk, nursing technicians, and nurse involved in the initial assessment and referral process. It is important to note that these costs were not specific to the pelvic service, but they were necessary for the screening flow.
The original sample consisted of 78 women, but 43.6% were lost to follow-up. Dropout rates were similar in both the individual and group intervention groups. Reasons for dropping out included acute chronic disease, non-sexually transmissible diseases, urinary infections, and unexcused absences.
Overall, the study provides insights into the reach of the Pelvic Physical Therapy Service and highlights the challenges in recruiting and retaining participants. Further analysis is needed to understand the factors contributing to dropout and explore strategies to improve engagement in the program.
Effectiveness
The effectiveness of a Pelvic Physical Therapy Service for older women with urinary incontinence (UI) in Amazonas, Brazil was evaluated. The study found that both individual and group-based interventions resulted in significant improvements in pelvic floor muscle strength, power, endurance, and fast contraction capacity. There was also a significant decrease in urinary loss after the interventions. The cost for maintaining the professional activities for each patient was R$ 389.59, but the actual cost to the FUnATI service was lower due to a partnership with UFAM that expanded care capacity. Overall, the findings suggest that the Pelvic Physical Therapy Service was effective in improving UI symptoms and enhancing the quality of life for older women in Amazonas, Brazil.
Adoption
The Pelvic Physical Therapy Service for older women with urinary incontinence (UI) was implemented at the FUnATI Polyclinic in Amazonas, Brazil. The organization achieved a 100% institutional participation due to an existing cooperation agreement between the institution and the University, resulting in reduced operating costs. The service was staffed by an experienced pelvic floor physiotherapist and a professor from the UFAM Physical Therapy College. In terms of student participation, there were 5 volunteer positions and 1 position for a scholarship holder. It is important to mention that the physical therapist responsible for the service must possess specific skills and receive adequate training to provide assistance.
Implementation
The implementation process of the Pelvic Physical Therapy Service for older women with urinary incontinence (UI) in Amazonas, Brazil involved individual or group therapy sessions twice a week for an average of 18.9 sessions for group interventions and 16.87 sessions for individual ones. The service was open from Tuesdays to Fridays from 8 am to 12 pm, with interns assisting on Wednesdays and Fridays under the supervision of a physical therapist. New patient evaluations were conducted based on a waiting list, and the service flow included a reception, screening room, preliminary nursing evaluation room, physician's evaluation room, and a 15 m2 pelvic Physical Therapy room. The University of Amazonas (UFAM) sponsored the Physical Therapy room materials, and consumables were shared between the Functional Unity for Older Adults at the Integrative and Continuing Health Care Center (FUnATI) and the funds obtained from the project's approval in UFAM's Extension Curriculum Activity Program, totaling R$ 1,500.00. Other permanent materials were loaned from UFAM, and the physical space for the activities was provided by FUnATI. The workload was distributed among a physical therapist, an extension scholarship recipient, student volunteers, and a professor. Remuneration included R$ 22.36/h for the physical therapist, R$ 400.00/month for the extension fellow (n = 5), while student volunteers and the teacher did not receive remuneration for their service.
Maintenance
The Pelvic Physical Therapy Service for older women with urinary incontinence (UI) in Amazonas, Brazil, was implemented as part of a project aimed at improving the physical, mental, and social health of older adults. The service, which provides free care to users of the Brazilian Unified Health System (SUS), is aligned with the institution's objective of research, gerontological education, and social well-being. It has been actively maintained by the institution.
The costs associated with maintaining the service include human resources and the purchase of consumables. Specifically, the monthly cost of a physical therapist is R$ 1,503.00, and the monthly expenditure on consumables amounts to R$ 252.98. Therefore, the total cost for maintaining the service is R$ 1,755.98.
This maintenance process ensures the continuity of the Pelvic Physical Therapy Service and its provision of care for older women with UI. By keeping the service active, the institution demonstrates its commitment to improving the quality of life for older adults in Amazonas, Brazil. The costs associated with the maintenance are necessary to sustain the service's operations, ensuring that it remains available to SUS users who require care for UI.
Overall, the implementation and maintenance of the Pelvic Physical Therapy Service represent an important step in addressing UI among older women in Amazonas, Brazil. By utilizing the resources available at the university institution, the service contributes to the overall well-being of older adults and provides a valuable support system for managing UI.
Discussion
This study focused on the development process of a Pelvic Physical Therapy Service for older women with urinary incontinence (UI) in Amazonas, Brazil. The authors evaluated the implementation of the service using the RE-AIM framework, which assesses the dimensions of Reach, Effectiveness, Adoption, Implementation, and Maintenance. The findings showed that the specialized service resulted in increased knowledge, decreased symptoms, and improved self-satisfaction for women with UI. The study highlighted the need for more pelvic Physical Therapy services tailored to the unique needs of UI patients, considering the high prevalence of the condition in aging women. Conservative treatments such as kinesiotherapy and pelvic exercises were found to be effective in reducing UI symptoms, with group-based physiotherapy being equally effective and more cost-effective than individual sessions. However, patient dropout was observed, which may be influenced by factors such as mild symptoms, competing priorities, low literacy in physiotherapy, and stigma associated with UI. The study also identified the interinstitutional partnership between FUnATI and UFAM as a strength, which allowed for the expansion of care capacity and created a valuable learning environment for both patients and students. Overall, the study demonstrated the feasibility of implementing a specialized Pelvic Physical Therapy Service for older women with UI and provided valuable insights for clinicians and decision-makers.
Conclusion
The conclusion of the research paper highlights the effectiveness of a physiotherapy intervention for older women with urinary incontinence (UI) in Amazonas, Brazil. The study found that the intervention led to a significant improvement in the strength, power, endurance, and fast contraction capacity of the pelvic floor muscles. However, the study also observed a high dropout rate among participants.
Despite the high dropout rate, the institution decided to maintain the pelvic physical therapy service after the conclusion of the study, indicating its feasibility and potential for long-term implementation. The use of the RE-AIM framework in evaluating the service's development process proved valuable, providing insights for future dissemination to other gerontology programs. Additionally, the study serves as a model for specialized care for patients in different age groups, not limited to older women with UI.
The findings of the study highlight the potential benefits of conservative treatment for patients with UI. This suggests that physiotherapy interventions targeting the pelvic floor muscles can be effective in improving UI symptoms and should be considered as an initial treatment option. Overall, this research provides valuable insights into the development and evaluation of a specialized pelvic physical therapy service for older women with UI in Amazonas, Brazil, contributing to the understanding of UI management and its impact on quality of life.
Opportunities for Future Research
1. Investigate strategies to improve adherence and reduce dropout rates in pelvic physical therapy interventions for urinary incontinence in older women.
2. Explore the effectiveness and cost-effectiveness of individualized vs. group-based physiotherapy interventions for urinary incontinence in older women.
3. Examine the long-term maintenance and sustainability of pelvic physical therapy services for urinary incontinence in community settings.
4. Investigate the impact of health education strategies on increasing interest and motivation for participation in pelvic physical therapy interventions for urinary incontinence.
5. Explore the barriers and facilitators to the implementation and adoption of pelvic physical therapy services for urinary incontinence in different healthcare settings.
6. Assess the feasibility and effectiveness of specialized pelvic physical therapy services for urinary incontinence in diverse populations, including men and younger women.
