As the proportion of older adults in the population increases worldwide, age and lifestyle-related disease and disability are becoming more prevalent. More older adults will suffer from “geriatric giants” defined as immobility, instability, urinary incontinence (UI) and  intellectual impairment [1]. Prevention or improvement of motor and cognitive decline can be achieved with exergames [2]. However, UI is rarely, if ever, addressed in these games. As pelvic floor muscle training (PFMT) is the first-line treatment for UI in women of all ages, this study aimed to assess the clinical impact of an exergame intervention combining PFMT to lower limb strength, balance, and cognitive training in older women with urgency UI (UUI).

This is a pilot interventional cohort study with a pre-post design.

Population: 
We recruited community-dwelling women aged 60 and over with UUI or mixed UI (MUI) with urgency predominant symptoms, as confirmed by the Questionnaire for Urinary Incontinence Diagnosis (QUID), who reported at least three episodes of urinary leakages on a 7-day bladder diary. To be included in the study, participants had to be able to maintain an upright position without support for at least 10 minutes and agree to participate in the study. Women were excluded if they could not contract their pelvic floor muscles (PFM), as verified by digital palpation, had a genital prolapse beyond the margin of the vulva, underwent physiotherapy, took medication, or had surgery for UI in the last year.

Intervention: 
Participant eligibility was first assessed by phone interview and then during an in-person pelvic floor physiotherapy evaluation. Women included in the study took part in two 45-minute sessions per week of personalized training with the exergame, supervised by a physiotherapist for 12 weeks. To do so, they wore foot sensors (inertial) and a vaginal sensor (dynamometer) to interact with the game. Ten virtual minigames required double and triple tasking, combining multidirectional stepping (triggering lower limb strength and balance), PFM contractions (activating PFM function) and/or cognitive and mental work (triggering attention, memory and inhibition aspects) (See Figure 1 for visuals of the exergame). In addition, participants were required to complete a PFM exercise program at home, three days/week. 

Outcomes: 
Data collected during the initial evaluation included demographics, medical history, level of activity, in addition to history and fear of falling. We assessed UI symptoms with a 7-day bladder diary and the ICIQ-UI SF, UI specific quality of life (QoL) with the ICIQ-LUTSquol, and PFM function with digital palpation and intra-vaginal electromyography (EMG). We also performed the Montreal Cognitive Assessment (MoCA) to assess cognition and the 1-minute Sit-to-Stand (1-MSTS) test for the functional assessment. At the end of the 12-week program, participants repeated the complete evaluation and questionnaires.

Data analysis:
For the main analysis of the clinical impacts (UI symptoms and UI specific QoL, PFM function and activation, cognitive and lower limb function), data were analyzed with mixed linear methods.

Eighteen women were included in this study. They had a mean age of 72.2 (SD 5.4) years, a mean BMI of 27.4 (SD 5.7) kg/m2 and a mean of 15.5 (SD 3.1) years of education. These participants had a mean number of 3.4 (SD 2.1) comorbidities, the most common being joint disease (8 participants; 44.4%), high blood pressure (8; 44.4%) and gastric disease (5; 27.8%). Most participants (12; 66.7%) were performing physical activity at least twice per week. Four (22.2%) participants reported being "at least occasionally afraid to fall", and six (33.3%) "fell at least once" in the last six months. UI symptoms began in the last five years for 11 women (61.1%). Four participants had UUI (22.2%), while the other 14 (77.8%) had MUI with predominant urgency symptoms. Only three women (16.7%) had previous experience with an exergame. 

Two women withdrew after the initial assessment due to lack of time. Results are presented for the 16 remaining participants. For UI symptoms, there was a significant mean reduction in leakage episodes of 2.14 episodes/day (95% CI; -3.54 to -0.71) on the 7-day bladder diary and a significant mean reduction of 7.17 points on the ICIQ-UI SF (95% CI; -9.26 to -5.15). For UI specific QoL, there was a significantly mean reduction of 8.88 points (95% CI; -13.29 to -4.39) on the ICIQ-LUTSqol. Furthermore, there were significant increases in mean Oxford scale scores on the following: the vaginal digital evaluation for strength (P) with 0.60 points (95%CI; 0.38 to 0.83), endurance (E) with 2.98 seconds (95% CI; 1.79 to 4.20), number of repetitions (R) with 2.65 repetitions (95% CI; 1.60 to 3.68), and number of fast contractions (F) with 2.16 repetitions (95% CI; 0.86 to 3.43). Additionally, there was a significant increase in EMG recordings during maximal contractions with a mean increase of 3.74µV (95% CI; 0.68 to 6.81). See Table 1 for more details. 

Of interest, there was a significant improvement in MoCA scores with a mean increase of 1.22 points (95% CI; 0.34 to 2.13) and a significant improvement in the 1-MSTS test scores with a mean increase of 2.43 repetitions (95%CI; 0.48 to 4.40).

Eighteen women were included in this pre-post designed exergame pilot interventional cohort study. Two women withdrew after the initial assessment due to lack of time. All others completed the study. After the intervention, the mean reduction in urine leakages on the 7-day diary showed an improvement of about 68%, which is a clinically important difference considering the 50% threshold for the minimal clinically important difference (MCID). 

UI severity and UI-specific QoL questionnaires also reached the MCID for both the ICIQ-UI SF with 7.17 compared to 2.52 points, and the ICIQ-LUTSqol with 8.88 points compared to 3.71 [3]. PFM function and activation also showed significant improvement, which could have contributed to the alleviation of UI symptoms. 

Furthermore, the exergame appeared to have positive impacts beyond the PFM, with statistically significant improvement on cognitive and physical function.

An exergame combining strength, balance and cognitive training with PFM exercises could be an interesting approach for treating UUI in older women, as well as preventing/targeting other important geriatric giants. Randomized controlled studies are needed to confirm these results.

Isaacs B. An Introduction to Geriatrics: London: Baillière: Tindall & Cassell; 1965.
Swinnen N, de Bruin ED, Dumoulin C, Thalmann M, Guimarães V, De Jong J, Vandenbulcke M, & Vancampfort D. (2021) The VITAAL Stepping Exergame Prototype for Older Adults With Major Neurocognitive Disorder: A Usability Study. Frontiers in aging neuroscience, 13, 701319. doi:10.3389/fnagi.2021.701319
Nyström E, Sjöström M, Stenlund H, Samuelsson E. ICIQ symptom and quality of life instruments measure clinically relevant improvements in women with stress urinary incontinence. Neurourol Urodyn. 2015 Nov;34(8):747-51. doi: 10.1002/nau.22657.

Continence 7S1 (2023) 100945
DOI: 10.1016/j.cont.2023.100945