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Group Treatment of Female Urinary Incontinence
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Key Words Urinary incontinence, group treatment, groups.
Group Treatment of Female Urinary Incontinence
by Teresa Cook
Literature review
Summary The purpose of this article is to review the evidence relating to the group treatment of female urinary incontinence, specifically relating to the theoretical framework and the effect of group treatment on the strength of pelvic floor muscles, bladder training and the improvement of patient knowledge. A literature search was performed using Medline, CINAHL, ASSIA, Embase:Physical Medicine and Rehabilitation, Physiotherapy Index, Rehabilitation Index and Complementary Medicine Index from 1987 to 1997. Eight articles were found which described the treatment of female urinary incontinence in a group environment. For group treatment to be effective the group itself must constitute an important element in the therapeutic process and consideration must be given to group dynamics. Analysis of the literature revealed that these processes had been poorly considered, despite the theoretical background of group treatment being well established. There were flaws in the design of several of the studies and also in the evaluation of the effect of group treatment on the strength of pelvic floor muscles, bladder training and improvement of patient knowledge. Further research is required, including the development of appropriate outcome measures and the use of control groups, to determine the effectiveness of this approach.
Cook, T (2001). ‘Group treatment of female urinary incontinence: Literature review’, Physiotherapy, 87, 5, 226-234.
Introduction Kegel (1951) described the use of pelvic floor exercises as a treatment for female stress urinary incontinence, and some physiotherapists have provided exercise therapy for this condition, either individually or in groups, since that time (Polden and Mantle, 1990). In more recent years, through the efforts of both the health professions and campaigning organisations, the problem of urinary incontinence has achieved heightened public awareness with resultant changes in public attitudes and expectations of treatment (Royal College of Physicians, 1995). The publication of research which
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questions the effectiveness of surgery for stress incontinence (Black et al, 1997) and the increasing profile of physiotherapists who specialise in the treatment of urinary incontinence has resulted in an increased physiotherapy referral rate for the assessment and treatment of this client group (Cowmeadow, 1996; Vestergaard, 1997). With ever-increasing pressure on resources it is essential that those available are put to best use. This means that treatment must be proven to be both clinically and cost effective and based on best available evidence. One method of improving throughput in a physiotherapy outpatient department, therefore providing a more cost-effective service, is to use groups to treat patients with similar conditions. Groupwork has been used by physiotherapists for many years as a method of providing both exercise therapy and planned patient education programmes (Gardiner, 1983; Hill, 1997). In the specialty of women’s health, groups have been used in both ante-natal and post-natal situations and have included the teaching of pelvic floor exercises, although the use of groups for treatment of urinary incontinence is less common. In presenting the results of a survey of physiotherapeutic treatment of urinary stress incontinence, Mantle and Versi (1991) made no reference to group treatment. As recently as 1997 a further survey, published by Vestergaard, indicated that only 21% of physiotherapists were using group sessions at that time, although a further 66% expressed an interest in initiating group sessions as a new activity. The purpose of this paper is to discuss the evidence relating to the group treatment of female urinary incontinence in terms of:
Professional articles
■ The theoretical framework of group
treatment. ■ The effect of group treatment on the
strength of pelvic floor muscles. ■ The effect of group treatment on
bladder training. ■ The effect of group treatment on the
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known to the author of this review as an abstract presented at the Chartered Society of Physiotherapy (CSP) Congress in 1994. Vigorous attempts were made through both the CSP and colleagues in The Netherlands to obtain the complete article but have been successful only in discovering the published abstract.
improvement of patient knowledge. Method It was expected that there would be little evidence available on the selected topic and any decision regarding narrowing of the subject matter or types of studies included in the review would be made after a preliminary search of all available databases. This search was per formed using Medline, CINAHL, ASSIA, Embase:Physical Medicine and Rehabilitation, Physiotherapy Index, Rehabilitation Index and Complementary Medicine Index from 1987 to 1997. The keyword/textword ‘urinary incontinence’ was used in addition to either ‘group’, ‘groups’, ‘group treatment’ or ‘group therapy’. This broad search retrieved many citations which were irrelevant but it was felt that this method was necessary in order to ensure all relevant information was located. The database abstracts of all the references revealed by the above search were read to determine the relevance of each article to the topic in question. Articles included as relevant were those describing treatment of female urinary incontinence in a group situation. Articles which did not include the use of groups for treatment, which referred to faecal incontinence or which used other modalities of treatment (eg electrical stimulation or biofeedback therapy) in addition to groupwork were excluded from the study. The preliminary search revealed six relevant references and it was therefore decided that no further narrowing of the topic was required. The reference lists of these articles were studied in order to locate any relevant documents which had not previously been identified. A further two references were discovered as a result of this and these papers were also included in the review giving a total of eight studies. One article by Marion Borghuis (1994), a Dutch physiotherapist, was referenced by Vestergaard (1997) and
Results Of the eight studies, two are randomised clinical trials (Bo et al, 1990; O’Brien et al, 1991), four are cohort studies with no control or comparing group (Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; Schofield and Wheaton, 1992), one is the published abstract of a pilot study (Borghuis, 1994) and the other is a survey (Vestergaard, 1997). 1. The theoretical framework of group treatment There is an absence of acknowledgment of the theoretical framework and role of group processes in all of the studies in this review. Most of the studies consist of treatment over a period of time, the longest being that by Bo et al (1990), who compared women who attended a pelvic floor muscle exercise course, training with an instructor in groups for 45 minutes once a week over six months (intensive exercise group), with a home exercise group. Although the results were significant, Bo attributes this to the degree and duration of treatment and frequent supervision by the therapist, and does not consider the effects of group processes. As the two groups in her study were instructed to perform their exercises at different degrees and no information is published about the training diaries, it is not possible to ascertain whether the group processes were a contributory factor to the published results and further research would be needed to determine these effects. Schofield and Wheaton (1992) studied a group of six women attending a support/education programme. They included in their objectives the provision of opportunities for socialising and mutual self-help, as well as the giving and sharing of information. Their remaining objectives, however, were not group specific and the results of the evaluation schedules, based on the objectives of the programme, were not presented. Results were published with regard to changes
Author Teresa Cook GradDipPhys MCSP is a physiotherapy clinical specialist in women’s health at the James Paget Hospital, Great Yarmouth. This literature review was undertaken as part of the University of East London graduate certificate in professional development in health: continence (1997-1998). The author wishes to acknowledge support from the James Paget Healthcare NHS Trust and the HSA Charitable Trust. This article was received on February 4, 1999, and accepted on June 3, 1999. Address for Correspondence Teresa Cook, Physiotherapy Department, James Paget Hospital, Great Yarmouth NR31 6LA.
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in continence state and patterns of socialising, but in the absence of a control group these again cannot be attributed to the group format. O’Brien et al (1991) conducted a survey to determine the prevalence of regular incontinence (two or more leaks in any one month) in adults aged 35 years and over registered in two large general practices in the UK. He then offered pelvic floor exercise classes to all patients found to have regular incontinence. Attendance over the four-session course was poor, with only 41% attending all four classes and 35% attending only one class. Patients who were very elderly or immobile were visited at home and this may account for the 8% who attended none of the classes. There was no measure of the effect of the group environment, neither was there any differentiation of the results in terms of attendance level. Again, little consideration seems to have been given to the influence of group processes. The study by Miles and Cochrane (1988) consisted of six sessions and that of Meek et al (1989) consisted of seven. There was no evaluation of the group format and the lack of a control group as well as other inadequacies in the papers results in the reviewer being unable to determine the importance of the group in these studies. The studies by Vestergaard (1997) and Gerard (1997) both consisted of a single advisory/information group session. Again there was no attempt to evaluate the influence of group processes although Vestergaard (1996) listed one of the benefits of group treatment being that, in a group situation with other sufferers, women may gain confidence to discuss practical problems and issues, learn from each other and find inspiration to motivate their rehabilitation. The abstract by Borghuis (1994) does not give sufficient information to determine whether she had considered the theoretical framework and therefore no comment is possible on this study. 2. The effect of group treatment on the strength of pelvic floor muscles Seven of the studies (Bo et al, 1990; Borghuis, 1994; Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992) used pelvic floor exercises in group Physiotherapy May 2001/vol 87/no 5
sessions although evaluation of the effectiveness of these exercises was generally poor. Bo et al (1990) found that while both home and intensive exercise groups in her study obtained a significant increase in maximal pelvic floor muscle strength, the increase was significantly larger in the intensive exercise group. She also recorded significant improvements in maximum urethral closure pressure, both at rest and during coughing, and a significant decrease in leakage at pad testing in the intensive exercise group. There was, however, no evaluation of the effect of group treatment on the strength of the pelvic floor muscles. As previously mentioned, the results were attributed to therapist supervision and degree and duration of treatment. O’Brien et al (1991) offered pelvic floor exercise classes to all patients found to have regular incontinence. These classes took place weekly and were supervised by a nurse, patients being taught ‘a series of structured exercises aimed at improving pelvic tone’ over a four-session course. They were advised to continue the exercises at home for a further eight weeks. There are no details of the exercises taught and the results, obtained after the 12-week programme, were presented as self-reporting of the ability to interrupt urinary stream, with no objective measure. As this method of assessing the pelvic floor muscles is neither valid nor reliable, due to several unmeasured variables including urinary flow rate, it is not possible to evaluate the effectiveness of group training on the strength of the pelvic floor muscles in this study. The other five studies (Borghuis, 1994; Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; Schofield and Wheaton, 1992) all claim to instruct participants in pelvic floor exercises. No details are given with regard to the frequency or intensity of the suggested exercise programmes, neither are any results presented on changes in pelvic floor muscle strength, giving no indication of the effectiveness of the programme with regard to this parameter. 3. The effect of group treatment on bladder training Five studies (Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien
Professional articles
et al, 1991; Schofield and Wheaton, 1992) included bladder training as part of the group treatment, although the lack of a control or comparing group in four of them, as well as poor methodology, reduced the significance of the results of these studies. The study by O’Brien et al (1991) claims to introduce a bladder training programme for patients with symptoms of urge incontinence, four weeks after starting pelvic floor exercises. This fourth session was the last group session and the programme was therefore continued on an individual, rather than group, basis. It should be noted that results were obtained by subjective measures, the patients being asked in pre- and post-test interviews if they could ‘hold on’ for five minutes. Results were given for the whole sample rather than for those with urge incontinence symptoms attending the fourth session. It is therefore not possible to determine the effectiveness of group treatment on bladder training in this study. Gerard (1997) taught techniques of decreasing bladder contractions to his study group, including the use of dietary alternatives that are less irritating to the bladder, although no further details are given on either the advice or compliance. Results are again obtained by subjective measures and as there are no details or results it is not possible to determine the effect of the group treatment on bladder training in this study. Miles and Cochrane (1988) taught bladder training as part of a six-session programme. However, their findings that patients with sensory urge were toileting two-and-a-half to three-hourly are irrelevant in the absence of any baseline statistics. Two other studies (Meek et al, 1989; Schofield and Wheaton, 1992) also taught bladder retraining techniques but these studies failed to give any details of the techniques used and reported no results. 4. The effect of group treatment on the improvement of patient knowledge No studies evaluated the level of knowledge of participants either before or after treatment although two studies (Schofield and Wheaton, 1992; Vestergaard, 1997) involved participants in planning the content of the group sessions.
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Discussion 1. The theoretical framework of group treatment The topic of group processes and their relevance to group treatment has been studied by psychologists and sociologists for many years, with the presentation of many opposing theories (Forsyth, 1990). Due to the mass of information and the restraints imposed by the general criteria of this paper it is not possible to discuss all of these theories. The aim is therefore to consider some of the available evidence which is of particular relevance to physiotherapists. The definition of a group is ‘a number of persons or things close together, or belonging or classed together’, with group therapy being defined as ‘therapy in which similarly affected patients are brought together to assist one another’ (Allen, 1990). The use of group learning can therefore only be deemed effective if it helps individuals achieve goals that they cannot achieve on their own, with the group itself constituting an important element in the therapeutic process (Forsyth, 1990). There are several characteristics which are important in group treatment. These include: ■ Interaction -- the way in which
members influence one another’s behaviour. ■ Goals -- the pursuit of common goals
will unite the members of a group. ■ Cohesiveness -- participation and
communication are greater in highly cohesive groups, as are enjoyment and satisfaction levels. ■ Change -- as groups develop they follow
a pattern of change. Group structure and size are also important in determining behaviour and interdependence, as is leadership, as this role is responsible for ensuring the function of the group in terms of the above characteristics (Forsyth, 1990). Before discussing these characteristics it is important to consider the theory of group formation, as this emphasises the usefulness of groups for individual members. Membership of a group allows individuals to compare themselves to others. This comparison is usually with other group members who are performing less effectively than themPhysiotherapy May 2001/vol 87/no 5
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selves, thereby protecting their own sense of self-worth, and is known as social comparison. Groups also satisfy many of our interpersonal needs, providing social support and a respite from loneliness (Forsyth, 1990). Studies on the impact of female urinary incontinence describe it as a taboo, meaning not only that it is a socially unacceptable topic of conversation but that it often results in the use of secrecy as a coping mechanism (Ashworth and Hagan, 1993). Responses to the problem are variable but include embarrassment, frustration and anxiety as well as social isolation (Wyman, 1994). The difficulties in acknowledging the problem are not relevant in this review, as these will already have been overcome in order for the individual to obtain a physiotherapy referral. Once treatment has been sought, the capacity for comparison and support within a group reduces both feelings of isolation and the need for secrecy. For this reason alone the use of groups should be considered (Forsyth,1990). Returning to the characteristics previously listed, the pursuit of a common goal will be present in the group under consideration, the objective being to promote continence using a variety of methods, and from this goal, given the correct structure, size and leadership, group interaction and cohesiveness should follow as the group develops. Group development follows a pattern of change and it is thought that unless these changes occur, members will not benefit from the experience. The following summary of this process is based on the work of Forsyth (1990). When a group forms, members are unfamiliar with each other, which can result in a reluctance to discuss personal views and values due to members feeling uncomfortable and constrained. This is particularly relevant when dealing with a group of women with urinary incontinence and the associated feelings and responses which have already been mentioned and is known as forming or orientation. Once these initial inhibitions have subsided, group members usually start to exchange information. The next stage of group development is conflict, with disagreements and tensions within the group resulting in interaction. This stage is also known as storming and is followed by a period of cohesion Physiotherapy May 2001/vol 87/no 5
(norming) with increased group unity, stability and satisfaction. Once the cohesion stage is achieved there is a tendency for the group to retain its members, with the presence of stronger influences and pressures to conform. During the fourth stage, termed performing, considerable change occurs with improved productivity and therapeutic progress. It should be noted that time is needed to allow the group to mature to this stage. The final stage of adjourning occurs with dissolution of the group, which takes place when the goals have been achieved or the group fails to satisfy its members’ needs. Both Vestergaard (1997) and Gerard (1997) use a single group session and therefore do not allow the group to follow the development process to maturity. These studies use the group merely as a method of advice and information giving and there can be little interaction and cohesion in such a newly-formed, and therefore immature, group. There is a failure by both authors to comment on this in their studies. The remaining six studies (Bo et al, 1990; Borghuis, 1994; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992) make no reference to the processes of group development and maturity. Another factor which influences the effectiveness of group intervention is that of pre-training (Forsyth, 1990) which will reduce members’ anxieties about the group experience and facilitate change. It need not be elaborate to be effective, possibly taking the format of written, verbal or visual information about the group, but results in more positive therapeutic outcomes. It seems to have been considered, without acknowledgement, by the authors and dealt with by a variety of methods. One study (Schofield and Wheaton, 1992) involved its participants in planning the programme, while another (Vestergaard, 1997) sent an explanatory letter and questionnaire relating to the topics available for discussion. In the latter study, Vestergaard (1997) noticed that participants receiving the information had thought about the topics, prepared questions and initiated more discussion than the women in groups prior to the survey. It is not possible to determine whether
Professional articles
there was any pre-training in the studies by Borghuis (1994) or Gerard (1997) due to the lack of substantiating information. In the other five studies (Bo et al, 1990; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992) the participants were informed about the group format on assessment, before they commenced the course. Attendance at the group sessions, where stated, was generally good, with the exception of the study by O’Brien et al (1991) who, while presenting data with regard to attendance, made little comment about it in the text. Cowmeadow (1996), in an audit of treatment groups, noticed a high initial ‘did not attend’ rate in groups who received an explanatory letter, but results are unclear with regard to a comparison with a group receiving no information and as the audit had not been completed before publication, the results cannot be regarded as reliable. 2. The effect of group treatment on the strength of pelvic floor muscles The main group processes which need to be considered with regard to this effect are conformity and social facilitation (Forsyth, 1990). These processes only become relevant, however, if participants are performing the correct exercises and the main concern is therefore that the ability of each participant to perform correct pelvic floor muscle exercises is determined. A study by Bump et al (1991) established that 51% of women are not able to per form an effective pelvic floor contraction after brief verbal instruction and that approximately half of these women display a technique which could potentially promote incontinence. He concludes that some type of feedback is required to determine pelvic floor ability, for example vaginal palpation, pressure biofeedback or electro-myographic biofeedback. This is accepted practice by physiotherapists and in the study by Bo et al (1990) there is individual instruction in pelvic floor anatomy and pelvic floor muscle exercises, as well as vaginal and perineal assessment of the ability to perform the correct muscle contraction, before starting the treatment. The women were also tested at monthly intervals during the course which gave the
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instructor the opportunity to correct the exercises if required. The study by Borghuis (1994) contains insufficient information with regard to pelvic floor assessment but none of the remaining six studies (Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992; Vestergaard, 1997) reported the use of vaginal examination to assess pelvic floor ability. Vestergaard (1997) performed no assessment before starting treatment, Gerard (1997) requested participants to complete a questionnaire, while the other studies (Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992) performed individual interviews. In the case of O’Brien et al (1991) this included urodynamic assessment. None of these six studies identified the potential problem caused by absence of assessment of the pelvic floor and it is unfortunate that the opportunity to teach and assess pelvic floor muscle exercises was missed in those studies that per formed an individual inter view. Furthermore they give no information with regard to the actual instructions used in teaching the exercises. O’Brien et al (1991) described ‘a series of structured exercises aimed at improving pelvic tone’ and Gerard (1997) described ‘specific exercises to address the different types of muscles found in the pelvic region’ but no details of the exercise programmes were given. The effectiveness of the pelvic floor exercises is therefore not demonstrated in any study except that by Bo et al (1990). Once it has been established that the exercises are being performed correctly there is great potential in using groups to improve compliance and morale, thereby improving the outcome of treatment. This occurs by the previously mentioned processes of conformity and social influence (Forsyth, 1990). Conformity often occurs in group situations owing to a number of social influence pressures including the fear of negative consequences that nonconformity may produce and the personal feeling that an individual must live up to others’ expectations (Forsyth, 1990). Also to be considered is the hypothesis that people work more effectively when others are present, ie that performance Physiotherapy May 2001/vol 87/no 5
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will be enhanced. This is illustrated by Thow (1990; 1990/91) who performed two studies, relating to compliance with a programme of pelvic floor exercises, on the same group of women. The first study involved a home exercise programme. The second study included attendance at a class, written exercise instructions and the use of other cues to per form the exercises. It was found that compliance with the exercises was greater in the second study. While acknowledging the role of ‘cues to action’ Thow (1990/91) commented that working in a group may create cohesion and motivation and provide fun and enjoyment, thereby reinforcing the required behavioural changes. 3. The effect of group treatment on bladder training The same group processes of conformity and social influence are applicable for bladder training. The techniques used to improve bladder capacity and resist the urge to void, therefore reducing he frequency of micturition, require motivation and determination over a period of time (Getliffe and Dolman, 1997). Physiotherapists recognise and often warn patients that the retraining programme may result in instances of leakage and that sustained effort is required to achieve results. Support from other group members, also working at the training programme, can be invaluable. Members can share information and provide collective encouragement for improvement and social support when individuals experience setbacks. With the previously acknowledged feelings of isolation experienced by women with urinary incontinence this may be the only forum that group members have to discuss their problem. 4. The effect of group treatment on the improvement of patient knowledge Individual teaching allows for flexibility and compromise, with the education programme tailored to the needs of the individual patient (Hill, 1997). This can be both time-consuming and costly and many women presenting for treatment of urinary incontinence have similar education requirements, in terms of the holistic approach suggested by the Physiotherapy May 2001/vol 87/no 5
Association of Chartered Physiotherapists in Women’s Health (1994). Several groups of healthcare professionals may be used in the education of patients with urinary incontinence. Although these have been used to varying degrees in the articles studied, there seems to have been little consideration given to the effectiveness or combination of professionals involved. Schofield and Wheaton (1992) use a number of different professions to provide the education programme, including the continence nurse adviser, social worker, physiotherapist, occupational therapist and uro-gynaecologist, which was designed following discussion with the participants, before starting the course. The study by Borghuis (1994) also takes the multi-disciplinary approach using a physiotherapist, GP, physiciansexologist and pharmacy assistant. Within the current NHS the cost of providing the expertise present in these two studies would be prohibitive on an individual basis, but the cost is reduced significantly by using the group environment. Meek et al (1989) use a combination of a urology nurse and a physiotherapist while the other studies (Bo et al, 1990; Gerard, 1997; Miles and Cochrane, 1988; O’Brien et al, 1991; Vestergaard, 1997) are uniprofessional, using either a physiotherapist or nurse. Vestergaard (1997) used a patient questionnaire to determine whether her sample was interested in receiving information on a number of topics. The response to both the questionnaire and a patient satisfaction survey resulted in the compilation of guidelines for promotion of continence in group sessions (Vestergaard, 1996). However it should be noted that her use of a single group session would not be practical in discussing the number of topics she suggests. Cowmeadow (1998) acknowledges the importance of an outcome measure in relation to the information given to group members; indeed there is little value in giving information if it is neither understood nor used. Development work continues with regard to outcome measurement, as at present there is no standard tool with which to prove the benefit of treatment. Further work is therefore required before the effect of group treatment on the improvement of patient knowledge can be established.
Professional articles
Conclusions ■ The theoretical framework of group
treatment is well documented (Forsyth, 1990). However there is a lack of evidence available with regard to the effectiveness of this approach for the treatment of female urinary incontinence. ■ Individual instruction in pelvic floor
anatomy and pelvic floor muscle exercises, as well as vaginal and perineal assessment of the ability to perform correct pelvic floor muscle contraction, is a necessity before starting treatment if pelvic floor exercises are included in the programme (Bump et al, 1991). Further research is required to determine whether it is supervision by the therapist, as well as degree and duration of the treatment, which achieves increases in pelvic floor muscle strength or whether group training is an important contributory factor. ■ Further research is required, using
control groups, to determine the
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effectiveness of group treatment in comparison with individual treatment for bladder training. ■ Pre-training is an important element in
improving the effectiveness of the group by reducing members’ anxieties (Forsyth, 1990) and this need not be an elaborate process. ■ A group can be used as a method of
patient education but the development of a valid and reliable outcome measure is essential to ensure that the information given is both pertinent and understood. This measure should evaluate the various components of intervention in order to establish which elements are dealt with effectively by group treatment. ■ According to Forsyth (1990) the
effectiveness of group treatment depends on the group itself constituting an important element in the therapeutic process. The group must therefore be allowed to mature to give members the opportunity to learn from each other and to give each other support, guidance and feedback.
References Association of Chartered Physiotherapists in Women’s Health (1994). Standards of Good Practice in Women’s Health, Chartered Society of Physiotherapy, London. Allen, R E (ed) (1990). The Pocket Oxford Dictionary. Oxford University Press, 7th edn. Ashworth, P D and Hagan, M T (1993). ‘The meaning of incontinence: A qualitative study of non-geriatric urinary incontinence sufferers’, Journal of Advanced Nursing, 18, 1415-23.
Bump, R, Hurt, G, Fantl, J A and Wyman, J F (1991). ‘Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction’, American Journal of Obstetrics and Gynecology, 165, 322-329. Cowmeadow, H (1996). ‘Audit -- Groups for continence?’ Journal of the Association of Chartered Physiotherapists in Women’s Health, 79, 34-35. Cowmeadow, H (1998). Personal communication.
Black, N, Griffiths, J, Pope, C, Bowling, A and Abel, P (1997). ‘Impact of surgery for stress incontinence on morbidity: Cohort study’, BMJ, 315, 1493-98.
Forsyth, D R (1990). Group Dynamics, Brooks/Cole, California, 2nd edn.
Bo, K, Hagan, R H, Kvarstein, B, Jorgenson, J and Larsen, S (1990). ‘Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: III. Effects of two different degrees of pelvic floor muscle exercises’, Neurourology and Urodynamics, 9, 489-498.
Gerard, L (1997). ‘Group learning behaviour modification and exercise for women with urinary incontinence’, Urological Nursing, 17, 17-22.
Borghuis, M (1994). ‘Group remedial therapy in general practice for women with incontinence symptoms’, Physiotherapy, 80, 7, 486.
Gardiner, M D (1983). The Principles of Exercise Therapy, Bell and Hyman, London.
Getliffe, K and Dolman, M (1997). Promoting Continence: A clinical and research resource, Bailliere Tindall, London. Hill, J (1997). ‘A practical guide to patient education and information giving’, Bailliere’s Clinical Rheumatology, 11, 1, 109-127.
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Kegel, A (1951). ‘Physiologic therapy for urinary stress incontinence’, Journal of the American Medical Association, 146, 915-917.
Vestergaard, A (1996). Guidelines for the Promotion of Continence in Group Sessions, Portsmouth Healthcare NHS Trust.
Mantle, J and Versi, E (1991). ‘Physiotherapy for stress urinary incontinence: A national survey’, BMJ, 302, 753-755.
Vestergaard, A (1997). ‘Promoting continence in group sessions’, Journal of the Association of Chartered Physiotherapists in Women’s Health, 80, 27-29.
Meek, D, Thorne, P and Luker, A (1989). ‘Support groups for older women’, Nursing Times, 85, 46, 71-73. Miles, B and Cochrane, G (1988). ‘All under control’, Nursing Times, 84, 31, 62-65. O’Brien, J, Austin, M, Sethi, P and O’Boyle, P (1991). ‘Urinary incontinence: Prevalence, need for treatment, and effectiveness of intervention by nurse’, BMJ, 303, 1308-12.
Wyman, J F (1994). ‘The psychiatric and emotional impact of female pelvic floor dysfunction’, Current Opinion in Obstetrics and Gynecology, 6, 336-339. Bibliography Crombie, I K (1996). The Pocket Guide to Critical Appraisal, BMJ Publishing Group, London.
Polden, M and Mantle, J (1990). Physiotherapy in Obstetrics and Gynaecology, ButterworthHeinemann, Oxford.
Hicks, C M (1995). Research for Physiotherapists: Project design and analysis, Churchill Livingstone, London, 2nd edn.
Royal College of Physicians (1995). ‘Incontinence: Causes, management and provision of services. Report of a working party’, Royal College of Physicians, London.
Lorig, K and associates (1996). Patient Education: A practical approach, Sage Publications, London, 2nd edn.
Schofield, A and Wheaton, C (1992). ‘Support/education groups for people with urinary incontinence’, Australian Social Work, 45, 4, 31-40. Thow, M K (1990). ‘The use of taught pelvicfloor exercises in the strengthening of pelvicfloor muscles and the effect on genuine stress incontinence’, Journal of the Association of Chartered Physiotherapists in Obstetrics and Gynaecology, 67, 2-5. Thow, M K (1990/91). ‘Compliance with a programme of pelvic-floor exercise’, Journal of the Association of Chartered Physiotherapists in Obstetrics and Gynaecology, 68, 10-13.
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Morkved, S and Bo, K (1996). ‘The effect of post-natal exercises to strengthen the pelvic floor muscles’, Acta Obstetricia Gynecologica Scandinavica, 75, 382-385. Niewijk, A H and Weijts, W B M (1997). ‘Effects of a multi-media course on urinary incontinence’, Patient Education and Counseling, 30, 95-103. Nishimoto, T and Schunk, C (1987). ‘Group therapy: An alternative treatment approach’, Clinical Management, 7, 4, 16-18. Thomas, P, Costello, M and Davison, S (1997). ‘Group work in general practice’, Psychodynamic Counselling, 3, February, 3329-38.
Key Words Urinary incontinence, group treatment, groups.
Group Treatment of Female Urinary Incontinence
by Teresa Cook
Literature review
Summary The purpose of this article is to review the evidence relating to the group treatment of female urinary incontinence, specifically relating to the theoretical framework and the effect of group treatment on the strength of pelvic floor muscles, bladder training and the improvement of patient knowledge. A literature search was performed using Medline, CINAHL, ASSIA, Embase:Physical Medicine and Rehabilitation, Physiotherapy Index, Rehabilitation Index and Complementary Medicine Index from 1987 to 1997. Eight articles were found which described the treatment of female urinary incontinence in a group environment. For group treatment to be effective the group itself must constitute an important element in the therapeutic process and consideration must be given to group dynamics. Analysis of the literature revealed that these processes had been poorly considered, despite the theoretical background of group treatment being well established. There were flaws in the design of several of the studies and also in the evaluation of the effect of group treatment on the strength of pelvic floor muscles, bladder training and improvement of patient knowledge. Further research is required, including the development of appropriate outcome measures and the use of control groups, to determine the effectiveness of this approach.
Cook, T (2001). ‘Group treatment of female urinary incontinence: Literature review’, Physiotherapy, 87, 5, 226-234.
Introduction Kegel (1951) described the use of pelvic floor exercises as a treatment for female stress urinary incontinence, and some physiotherapists have provided exercise therapy for this condition, either individually or in groups, since that time (Polden and Mantle, 1990). In more recent years, through the efforts of both the health professions and campaigning organisations, the problem of urinary incontinence has achieved heightened public awareness with resultant changes in public attitudes and expectations of treatment (Royal College of Physicians, 1995). The publication of research which
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questions the effectiveness of surgery for stress incontinence (Black et al, 1997) and the increasing profile of physiotherapists who specialise in the treatment of urinary incontinence has resulted in an increased physiotherapy referral rate for the assessment and treatment of this client group (Cowmeadow, 1996; Vestergaard, 1997). With ever-increasing pressure on resources it is essential that those available are put to best use. This means that treatment must be proven to be both clinically and cost effective and based on best available evidence. One method of improving throughput in a physiotherapy outpatient department, therefore providing a more cost-effective service, is to use groups to treat patients with similar conditions. Groupwork has been used by physiotherapists for many years as a method of providing both exercise therapy and planned patient education programmes (Gardiner, 1983; Hill, 1997). In the specialty of women’s health, groups have been used in both ante-natal and post-natal situations and have included the teaching of pelvic floor exercises, although the use of groups for treatment of urinary incontinence is less common. In presenting the results of a survey of physiotherapeutic treatment of urinary stress incontinence, Mantle and Versi (1991) made no reference to group treatment. As recently as 1997 a further survey, published by Vestergaard, indicated that only 21% of physiotherapists were using group sessions at that time, although a further 66% expressed an interest in initiating group sessions as a new activity. The purpose of this paper is to discuss the evidence relating to the group treatment of female urinary incontinence in terms of:
Professional articles
■ The theoretical framework of group
treatment. ■ The effect of group treatment on the
strength of pelvic floor muscles. ■ The effect of group treatment on
bladder training. ■ The effect of group treatment on the
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known to the author of this review as an abstract presented at the Chartered Society of Physiotherapy (CSP) Congress in 1994. Vigorous attempts were made through both the CSP and colleagues in The Netherlands to obtain the complete article but have been successful only in discovering the published abstract.
improvement of patient knowledge. Method It was expected that there would be little evidence available on the selected topic and any decision regarding narrowing of the subject matter or types of studies included in the review would be made after a preliminary search of all available databases. This search was per formed using Medline, CINAHL, ASSIA, Embase:Physical Medicine and Rehabilitation, Physiotherapy Index, Rehabilitation Index and Complementary Medicine Index from 1987 to 1997. The keyword/textword ‘urinary incontinence’ was used in addition to either ‘group’, ‘groups’, ‘group treatment’ or ‘group therapy’. This broad search retrieved many citations which were irrelevant but it was felt that this method was necessary in order to ensure all relevant information was located. The database abstracts of all the references revealed by the above search were read to determine the relevance of each article to the topic in question. Articles included as relevant were those describing treatment of female urinary incontinence in a group situation. Articles which did not include the use of groups for treatment, which referred to faecal incontinence or which used other modalities of treatment (eg electrical stimulation or biofeedback therapy) in addition to groupwork were excluded from the study. The preliminary search revealed six relevant references and it was therefore decided that no further narrowing of the topic was required. The reference lists of these articles were studied in order to locate any relevant documents which had not previously been identified. A further two references were discovered as a result of this and these papers were also included in the review giving a total of eight studies. One article by Marion Borghuis (1994), a Dutch physiotherapist, was referenced by Vestergaard (1997) and
Results Of the eight studies, two are randomised clinical trials (Bo et al, 1990; O’Brien et al, 1991), four are cohort studies with no control or comparing group (Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; Schofield and Wheaton, 1992), one is the published abstract of a pilot study (Borghuis, 1994) and the other is a survey (Vestergaard, 1997). 1. The theoretical framework of group treatment There is an absence of acknowledgment of the theoretical framework and role of group processes in all of the studies in this review. Most of the studies consist of treatment over a period of time, the longest being that by Bo et al (1990), who compared women who attended a pelvic floor muscle exercise course, training with an instructor in groups for 45 minutes once a week over six months (intensive exercise group), with a home exercise group. Although the results were significant, Bo attributes this to the degree and duration of treatment and frequent supervision by the therapist, and does not consider the effects of group processes. As the two groups in her study were instructed to perform their exercises at different degrees and no information is published about the training diaries, it is not possible to ascertain whether the group processes were a contributory factor to the published results and further research would be needed to determine these effects. Schofield and Wheaton (1992) studied a group of six women attending a support/education programme. They included in their objectives the provision of opportunities for socialising and mutual self-help, as well as the giving and sharing of information. Their remaining objectives, however, were not group specific and the results of the evaluation schedules, based on the objectives of the programme, were not presented. Results were published with regard to changes
Author Teresa Cook GradDipPhys MCSP is a physiotherapy clinical specialist in women’s health at the James Paget Hospital, Great Yarmouth. This literature review was undertaken as part of the University of East London graduate certificate in professional development in health: continence (1997-1998). The author wishes to acknowledge support from the James Paget Healthcare NHS Trust and the HSA Charitable Trust. This article was received on February 4, 1999, and accepted on June 3, 1999. Address for Correspondence Teresa Cook, Physiotherapy Department, James Paget Hospital, Great Yarmouth NR31 6LA.
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in continence state and patterns of socialising, but in the absence of a control group these again cannot be attributed to the group format. O’Brien et al (1991) conducted a survey to determine the prevalence of regular incontinence (two or more leaks in any one month) in adults aged 35 years and over registered in two large general practices in the UK. He then offered pelvic floor exercise classes to all patients found to have regular incontinence. Attendance over the four-session course was poor, with only 41% attending all four classes and 35% attending only one class. Patients who were very elderly or immobile were visited at home and this may account for the 8% who attended none of the classes. There was no measure of the effect of the group environment, neither was there any differentiation of the results in terms of attendance level. Again, little consideration seems to have been given to the influence of group processes. The study by Miles and Cochrane (1988) consisted of six sessions and that of Meek et al (1989) consisted of seven. There was no evaluation of the group format and the lack of a control group as well as other inadequacies in the papers results in the reviewer being unable to determine the importance of the group in these studies. The studies by Vestergaard (1997) and Gerard (1997) both consisted of a single advisory/information group session. Again there was no attempt to evaluate the influence of group processes although Vestergaard (1996) listed one of the benefits of group treatment being that, in a group situation with other sufferers, women may gain confidence to discuss practical problems and issues, learn from each other and find inspiration to motivate their rehabilitation. The abstract by Borghuis (1994) does not give sufficient information to determine whether she had considered the theoretical framework and therefore no comment is possible on this study. 2. The effect of group treatment on the strength of pelvic floor muscles Seven of the studies (Bo et al, 1990; Borghuis, 1994; Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992) used pelvic floor exercises in group Physiotherapy May 2001/vol 87/no 5
sessions although evaluation of the effectiveness of these exercises was generally poor. Bo et al (1990) found that while both home and intensive exercise groups in her study obtained a significant increase in maximal pelvic floor muscle strength, the increase was significantly larger in the intensive exercise group. She also recorded significant improvements in maximum urethral closure pressure, both at rest and during coughing, and a significant decrease in leakage at pad testing in the intensive exercise group. There was, however, no evaluation of the effect of group treatment on the strength of the pelvic floor muscles. As previously mentioned, the results were attributed to therapist supervision and degree and duration of treatment. O’Brien et al (1991) offered pelvic floor exercise classes to all patients found to have regular incontinence. These classes took place weekly and were supervised by a nurse, patients being taught ‘a series of structured exercises aimed at improving pelvic tone’ over a four-session course. They were advised to continue the exercises at home for a further eight weeks. There are no details of the exercises taught and the results, obtained after the 12-week programme, were presented as self-reporting of the ability to interrupt urinary stream, with no objective measure. As this method of assessing the pelvic floor muscles is neither valid nor reliable, due to several unmeasured variables including urinary flow rate, it is not possible to evaluate the effectiveness of group training on the strength of the pelvic floor muscles in this study. The other five studies (Borghuis, 1994; Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; Schofield and Wheaton, 1992) all claim to instruct participants in pelvic floor exercises. No details are given with regard to the frequency or intensity of the suggested exercise programmes, neither are any results presented on changes in pelvic floor muscle strength, giving no indication of the effectiveness of the programme with regard to this parameter. 3. The effect of group treatment on bladder training Five studies (Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien
Professional articles
et al, 1991; Schofield and Wheaton, 1992) included bladder training as part of the group treatment, although the lack of a control or comparing group in four of them, as well as poor methodology, reduced the significance of the results of these studies. The study by O’Brien et al (1991) claims to introduce a bladder training programme for patients with symptoms of urge incontinence, four weeks after starting pelvic floor exercises. This fourth session was the last group session and the programme was therefore continued on an individual, rather than group, basis. It should be noted that results were obtained by subjective measures, the patients being asked in pre- and post-test interviews if they could ‘hold on’ for five minutes. Results were given for the whole sample rather than for those with urge incontinence symptoms attending the fourth session. It is therefore not possible to determine the effectiveness of group treatment on bladder training in this study. Gerard (1997) taught techniques of decreasing bladder contractions to his study group, including the use of dietary alternatives that are less irritating to the bladder, although no further details are given on either the advice or compliance. Results are again obtained by subjective measures and as there are no details or results it is not possible to determine the effect of the group treatment on bladder training in this study. Miles and Cochrane (1988) taught bladder training as part of a six-session programme. However, their findings that patients with sensory urge were toileting two-and-a-half to three-hourly are irrelevant in the absence of any baseline statistics. Two other studies (Meek et al, 1989; Schofield and Wheaton, 1992) also taught bladder retraining techniques but these studies failed to give any details of the techniques used and reported no results. 4. The effect of group treatment on the improvement of patient knowledge No studies evaluated the level of knowledge of participants either before or after treatment although two studies (Schofield and Wheaton, 1992; Vestergaard, 1997) involved participants in planning the content of the group sessions.
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Discussion 1. The theoretical framework of group treatment The topic of group processes and their relevance to group treatment has been studied by psychologists and sociologists for many years, with the presentation of many opposing theories (Forsyth, 1990). Due to the mass of information and the restraints imposed by the general criteria of this paper it is not possible to discuss all of these theories. The aim is therefore to consider some of the available evidence which is of particular relevance to physiotherapists. The definition of a group is ‘a number of persons or things close together, or belonging or classed together’, with group therapy being defined as ‘therapy in which similarly affected patients are brought together to assist one another’ (Allen, 1990). The use of group learning can therefore only be deemed effective if it helps individuals achieve goals that they cannot achieve on their own, with the group itself constituting an important element in the therapeutic process (Forsyth, 1990). There are several characteristics which are important in group treatment. These include: ■ Interaction -- the way in which
members influence one another’s behaviour. ■ Goals -- the pursuit of common goals
will unite the members of a group. ■ Cohesiveness -- participation and
communication are greater in highly cohesive groups, as are enjoyment and satisfaction levels. ■ Change -- as groups develop they follow
a pattern of change. Group structure and size are also important in determining behaviour and interdependence, as is leadership, as this role is responsible for ensuring the function of the group in terms of the above characteristics (Forsyth, 1990). Before discussing these characteristics it is important to consider the theory of group formation, as this emphasises the usefulness of groups for individual members. Membership of a group allows individuals to compare themselves to others. This comparison is usually with other group members who are performing less effectively than themPhysiotherapy May 2001/vol 87/no 5
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selves, thereby protecting their own sense of self-worth, and is known as social comparison. Groups also satisfy many of our interpersonal needs, providing social support and a respite from loneliness (Forsyth, 1990). Studies on the impact of female urinary incontinence describe it as a taboo, meaning not only that it is a socially unacceptable topic of conversation but that it often results in the use of secrecy as a coping mechanism (Ashworth and Hagan, 1993). Responses to the problem are variable but include embarrassment, frustration and anxiety as well as social isolation (Wyman, 1994). The difficulties in acknowledging the problem are not relevant in this review, as these will already have been overcome in order for the individual to obtain a physiotherapy referral. Once treatment has been sought, the capacity for comparison and support within a group reduces both feelings of isolation and the need for secrecy. For this reason alone the use of groups should be considered (Forsyth,1990). Returning to the characteristics previously listed, the pursuit of a common goal will be present in the group under consideration, the objective being to promote continence using a variety of methods, and from this goal, given the correct structure, size and leadership, group interaction and cohesiveness should follow as the group develops. Group development follows a pattern of change and it is thought that unless these changes occur, members will not benefit from the experience. The following summary of this process is based on the work of Forsyth (1990). When a group forms, members are unfamiliar with each other, which can result in a reluctance to discuss personal views and values due to members feeling uncomfortable and constrained. This is particularly relevant when dealing with a group of women with urinary incontinence and the associated feelings and responses which have already been mentioned and is known as forming or orientation. Once these initial inhibitions have subsided, group members usually start to exchange information. The next stage of group development is conflict, with disagreements and tensions within the group resulting in interaction. This stage is also known as storming and is followed by a period of cohesion Physiotherapy May 2001/vol 87/no 5
(norming) with increased group unity, stability and satisfaction. Once the cohesion stage is achieved there is a tendency for the group to retain its members, with the presence of stronger influences and pressures to conform. During the fourth stage, termed performing, considerable change occurs with improved productivity and therapeutic progress. It should be noted that time is needed to allow the group to mature to this stage. The final stage of adjourning occurs with dissolution of the group, which takes place when the goals have been achieved or the group fails to satisfy its members’ needs. Both Vestergaard (1997) and Gerard (1997) use a single group session and therefore do not allow the group to follow the development process to maturity. These studies use the group merely as a method of advice and information giving and there can be little interaction and cohesion in such a newly-formed, and therefore immature, group. There is a failure by both authors to comment on this in their studies. The remaining six studies (Bo et al, 1990; Borghuis, 1994; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992) make no reference to the processes of group development and maturity. Another factor which influences the effectiveness of group intervention is that of pre-training (Forsyth, 1990) which will reduce members’ anxieties about the group experience and facilitate change. It need not be elaborate to be effective, possibly taking the format of written, verbal or visual information about the group, but results in more positive therapeutic outcomes. It seems to have been considered, without acknowledgement, by the authors and dealt with by a variety of methods. One study (Schofield and Wheaton, 1992) involved its participants in planning the programme, while another (Vestergaard, 1997) sent an explanatory letter and questionnaire relating to the topics available for discussion. In the latter study, Vestergaard (1997) noticed that participants receiving the information had thought about the topics, prepared questions and initiated more discussion than the women in groups prior to the survey. It is not possible to determine whether
Professional articles
there was any pre-training in the studies by Borghuis (1994) or Gerard (1997) due to the lack of substantiating information. In the other five studies (Bo et al, 1990; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992) the participants were informed about the group format on assessment, before they commenced the course. Attendance at the group sessions, where stated, was generally good, with the exception of the study by O’Brien et al (1991) who, while presenting data with regard to attendance, made little comment about it in the text. Cowmeadow (1996), in an audit of treatment groups, noticed a high initial ‘did not attend’ rate in groups who received an explanatory letter, but results are unclear with regard to a comparison with a group receiving no information and as the audit had not been completed before publication, the results cannot be regarded as reliable. 2. The effect of group treatment on the strength of pelvic floor muscles The main group processes which need to be considered with regard to this effect are conformity and social facilitation (Forsyth, 1990). These processes only become relevant, however, if participants are performing the correct exercises and the main concern is therefore that the ability of each participant to perform correct pelvic floor muscle exercises is determined. A study by Bump et al (1991) established that 51% of women are not able to per form an effective pelvic floor contraction after brief verbal instruction and that approximately half of these women display a technique which could potentially promote incontinence. He concludes that some type of feedback is required to determine pelvic floor ability, for example vaginal palpation, pressure biofeedback or electro-myographic biofeedback. This is accepted practice by physiotherapists and in the study by Bo et al (1990) there is individual instruction in pelvic floor anatomy and pelvic floor muscle exercises, as well as vaginal and perineal assessment of the ability to perform the correct muscle contraction, before starting the treatment. The women were also tested at monthly intervals during the course which gave the
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instructor the opportunity to correct the exercises if required. The study by Borghuis (1994) contains insufficient information with regard to pelvic floor assessment but none of the remaining six studies (Gerard, 1997; Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992; Vestergaard, 1997) reported the use of vaginal examination to assess pelvic floor ability. Vestergaard (1997) performed no assessment before starting treatment, Gerard (1997) requested participants to complete a questionnaire, while the other studies (Meek et al, 1989; Miles and Cochrane, 1988; O’Brien et al, 1991; Schofield and Wheaton, 1992) performed individual interviews. In the case of O’Brien et al (1991) this included urodynamic assessment. None of these six studies identified the potential problem caused by absence of assessment of the pelvic floor and it is unfortunate that the opportunity to teach and assess pelvic floor muscle exercises was missed in those studies that per formed an individual inter view. Furthermore they give no information with regard to the actual instructions used in teaching the exercises. O’Brien et al (1991) described ‘a series of structured exercises aimed at improving pelvic tone’ and Gerard (1997) described ‘specific exercises to address the different types of muscles found in the pelvic region’ but no details of the exercise programmes were given. The effectiveness of the pelvic floor exercises is therefore not demonstrated in any study except that by Bo et al (1990). Once it has been established that the exercises are being performed correctly there is great potential in using groups to improve compliance and morale, thereby improving the outcome of treatment. This occurs by the previously mentioned processes of conformity and social influence (Forsyth, 1990). Conformity often occurs in group situations owing to a number of social influence pressures including the fear of negative consequences that nonconformity may produce and the personal feeling that an individual must live up to others’ expectations (Forsyth, 1990). Also to be considered is the hypothesis that people work more effectively when others are present, ie that performance Physiotherapy May 2001/vol 87/no 5
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will be enhanced. This is illustrated by Thow (1990; 1990/91) who performed two studies, relating to compliance with a programme of pelvic floor exercises, on the same group of women. The first study involved a home exercise programme. The second study included attendance at a class, written exercise instructions and the use of other cues to per form the exercises. It was found that compliance with the exercises was greater in the second study. While acknowledging the role of ‘cues to action’ Thow (1990/91) commented that working in a group may create cohesion and motivation and provide fun and enjoyment, thereby reinforcing the required behavioural changes. 3. The effect of group treatment on bladder training The same group processes of conformity and social influence are applicable for bladder training. The techniques used to improve bladder capacity and resist the urge to void, therefore reducing he frequency of micturition, require motivation and determination over a period of time (Getliffe and Dolman, 1997). Physiotherapists recognise and often warn patients that the retraining programme may result in instances of leakage and that sustained effort is required to achieve results. Support from other group members, also working at the training programme, can be invaluable. Members can share information and provide collective encouragement for improvement and social support when individuals experience setbacks. With the previously acknowledged feelings of isolation experienced by women with urinary incontinence this may be the only forum that group members have to discuss their problem. 4. The effect of group treatment on the improvement of patient knowledge Individual teaching allows for flexibility and compromise, with the education programme tailored to the needs of the individual patient (Hill, 1997). This can be both time-consuming and costly and many women presenting for treatment of urinary incontinence have similar education requirements, in terms of the holistic approach suggested by the Physiotherapy May 2001/vol 87/no 5
Association of Chartered Physiotherapists in Women’s Health (1994). Several groups of healthcare professionals may be used in the education of patients with urinary incontinence. Although these have been used to varying degrees in the articles studied, there seems to have been little consideration given to the effectiveness or combination of professionals involved. Schofield and Wheaton (1992) use a number of different professions to provide the education programme, including the continence nurse adviser, social worker, physiotherapist, occupational therapist and uro-gynaecologist, which was designed following discussion with the participants, before starting the course. The study by Borghuis (1994) also takes the multi-disciplinary approach using a physiotherapist, GP, physiciansexologist and pharmacy assistant. Within the current NHS the cost of providing the expertise present in these two studies would be prohibitive on an individual basis, but the cost is reduced significantly by using the group environment. Meek et al (1989) use a combination of a urology nurse and a physiotherapist while the other studies (Bo et al, 1990; Gerard, 1997; Miles and Cochrane, 1988; O’Brien et al, 1991; Vestergaard, 1997) are uniprofessional, using either a physiotherapist or nurse. Vestergaard (1997) used a patient questionnaire to determine whether her sample was interested in receiving information on a number of topics. The response to both the questionnaire and a patient satisfaction survey resulted in the compilation of guidelines for promotion of continence in group sessions (Vestergaard, 1996). However it should be noted that her use of a single group session would not be practical in discussing the number of topics she suggests. Cowmeadow (1998) acknowledges the importance of an outcome measure in relation to the information given to group members; indeed there is little value in giving information if it is neither understood nor used. Development work continues with regard to outcome measurement, as at present there is no standard tool with which to prove the benefit of treatment. Further work is therefore required before the effect of group treatment on the improvement of patient knowledge can be established.
Professional articles
Conclusions ■ The theoretical framework of group
treatment is well documented (Forsyth, 1990). However there is a lack of evidence available with regard to the effectiveness of this approach for the treatment of female urinary incontinence. ■ Individual instruction in pelvic floor
anatomy and pelvic floor muscle exercises, as well as vaginal and perineal assessment of the ability to perform correct pelvic floor muscle contraction, is a necessity before starting treatment if pelvic floor exercises are included in the programme (Bump et al, 1991). Further research is required to determine whether it is supervision by the therapist, as well as degree and duration of the treatment, which achieves increases in pelvic floor muscle strength or whether group training is an important contributory factor. ■ Further research is required, using
control groups, to determine the
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effectiveness of group treatment in comparison with individual treatment for bladder training. ■ Pre-training is an important element in
improving the effectiveness of the group by reducing members’ anxieties (Forsyth, 1990) and this need not be an elaborate process. ■ A group can be used as a method of
patient education but the development of a valid and reliable outcome measure is essential to ensure that the information given is both pertinent and understood. This measure should evaluate the various components of intervention in order to establish which elements are dealt with effectively by group treatment. ■ According to Forsyth (1990) the
effectiveness of group treatment depends on the group itself constituting an important element in the therapeutic process. The group must therefore be allowed to mature to give members the opportunity to learn from each other and to give each other support, guidance and feedback.
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Morkved, S and Bo, K (1996). ‘The effect of post-natal exercises to strengthen the pelvic floor muscles’, Acta Obstetricia Gynecologica Scandinavica, 75, 382-385. Niewijk, A H and Weijts, W B M (1997). ‘Effects of a multi-media course on urinary incontinence’, Patient Education and Counseling, 30, 95-103. Nishimoto, T and Schunk, C (1987). ‘Group therapy: An alternative treatment approach’, Clinical Management, 7, 4, 16-18. Thomas, P, Costello, M and Davison, S (1997). ‘Group work in general practice’, Psychodynamic Counselling, 3, February, 3329-38.