Urinary incontinence (UI) is a highly prevalent health condition among women aged 65 and over. While pelvic floor muscle training (PFMT) is recommended as a first-line treatment, it is received by only a few women. Group-based treatment offers a cost-effective alternative [1, 2] that could improve treatment accessibility. Moreover, remote care options have expanded considerably in recent years, with telerehabilitation emerging as a promising care option. Recent evidence has demonstrated favorable clinical effects immediately after a group-based telerehabilitation PFMT program for UI in older women [3]. However, the effect of this program following unsupervised maintenance exercises is still unknown.

This study is part of a larger research program assessing the feasibility, acceptability, and clinical effects of online group-based PFMT immediately after the program and at a six-month follow-up after an unsupervised maintenance exercise regimen. This abstract presents the six-month follow-up results.
Selection of participants
Of the 34 participants enrolled in the original study, 33 completed the program. Eligible participants were women aged 65 and older, capable of walking independently, reporting stress or mixed UI as confirmed by the Questionnaire for Incontinence Diagnosis (QUID), with UI persisting for three months or more, and experiencing at least three urine leakages per week on the 7-day bladder diary. Additionally, participants were required to have internet access. Women who were unable to voluntarily contract their pelvic floor muscles (PFMs) or reporting any risk factors or conditions known to interfere with PFMT or the PFM evaluation were excluded.
Intervention
Pelvic floor physiotherapists assessed the eligibility of women during individual in-person evaluation sessions. These sessions confirmed the women’s ability to contract their PFMs and provided instruction on proper PFM contraction through vaginal digital palpation, as needed. 
Participants then engaged in a 12-week group-based PFMT program, consisting of weekly one-hour online training sessions along with a concurrent home-based exercise regimen to be performed five days per week. Participants were provided with an exercise diary and printed educational materials. Each session began with a brief individual exchange and feedback from the physiotherapist in a private virtual room, while the rest of the group socialized in the main virtual room. Subsequently, participants reconvened in the main virtual room for a 10- to 15-minute educational component and a 30- to 45-minute PFM exercise component. The exercise component included four main exercises targeting strength, contraction speed, coordination and endurance. Upon completion of the 12-week program, participants were instructed to continue with an unsupervised home-based maintenance exercise regimen three days per week, featuring a progressed version of the 12-week home exercise program.  
Data collection
During the initial in-person assessment, physiotherapists collected sociodemographic and general health data. 
Clinical data were collected at four timepoints: before the 12-week online program (PRE), at the end of the program (POST), and at three (3MO) and six months (6MO) after the end of program. 
Participants recorded UI symptoms using 7-day bladder diaries at PRE, POST and 6MO. They completed standardized questionnaires on UI-specific symptoms at PRE, POST and 6MO: the ICIQ-UI short form, the ICIQ-LUTSqol, and the bladder function subscale of the Australian Pelvic Floor Questionnaire (APFQ). Participants also completed standardized questionnaires on other symptoms and indicators at PRE, POST and 6MO: the bowel function, prolapse and sexual function subscales of the APFQ, the Atrophy Symptom Questionnaire (ASQ), the Geriatric Self-Efficacy (GSE) index, the Broome Pelvic Muscle Exercise Self-Efficacy Scale (PMSES), and the Online Technologies Self-Efficacy Scale (OTSES). Additionally, participants reported the monthly costs of disposable continence products using the adapted Dowell-Bryant Incontinence Cost Index (DBICI) at PRE, POST and 6MO. The primary outcome was leakage reduction.
Participants reported their adherence to the maintenance exercises and completed the Patient Global Impression of Improvement index (PGI-I) and questions on satisfaction at 3MO and 6MO.
Data analysis
For the primary outcome, the median percentage of leakage reduction between PRE and 6MO was calculated for each participant. 
Changes from PRE to POST, and from PRE and POST to 6MO, were reported as mean estimated values with corresponding 95% confidence intervals and analyzed using linear mixed models with Benjamini-Hochberg False Discovery Rate (FDR) correction for multiple comparisons. Models included time as fixed effect and random intercepts for each participant to account for repeated measures. If linearity assumptions were not met, outcomes were analyzed using Friedman tests and post-hoc Wilcoxon signed-rank tests. 
Adherence to the unsupervised maintenance exercise regimen at 3MO and 6MO, and PGI-I scores and satisfaction at 6MO were analyzed using descriptive statistics.

Of the 34 participants enrolled in the main study, 33 completed the 12-week program, and 32 completed the 6MO follow-up questionnaires and were included in the analyses. 
Participants achieved a median leakage reduction of 73% (38-88) from PRE to 6MO (Figure 1). Significant improvements were maintained from POST to 6MO across all UI-specific outcomes (Table 1). The mean number of leakage episodes per day decreased from 2.5 (1.9) at PRE to 1.3 (2.8) at 6MO (p<0.001). The mean ICIQ-UI short form score decreased from 12.6 (2.6) at PRE to 8.4 (4.3) at 6MO (p<0.001). The mean ICIQ-LUTSqol score decreased from 37.0 (10.1) at PRE to 29.4 (8.1) at 6MO (p<0.001). The mean APFQ Bladder Function subscale score decreased from 15.7 (5.3) at PRE to 11.1 (5.2) at 6MO (p<0.001). Changes from POST to 6MO were not statistically significant (p=0.499, p=0.877, p=0.854, and p=0.198, respectively), suggesting that improvements were maintained over time. Significant improvements were also maintained from POST to 6MO for three distinct outcomes of other symptoms and indicators. The mean number of micturitions per day decreased from 7.4 (2.3) at PRE to 6.5 (2.1) at 6MO (p=0.004). The mean GSE score increased from 61.2 (20.6) at PRE to 79.3 (26.2) at 6MO (p<0.001). The PMSES total mean score increased from 64.9 (14.7) at PRE to 74.8 (17.4) at 6MO (p<0.001). Changes from POST to 6MO were not statistically significant (p=0.505, p=0.053, and p=0.085, respectively), suggesting that improvements were maintained over time. 
Regarding adherence to the unsupervised exercise regimen, most participants completed a minimum of one exercise at least once per week at both 3MO (24/32, 75%) and 6MO (24/32, 75%).
At 6MO, most participants (28/32, 88%) reported that they perceived an improvement in their symptoms, with 15/32 (47%) reporting being ‘much better’, 9/32 (28%) ‘better’ and 4/32 (13%) ‘somewhat better’. Similarly, 27/32 (84%) were satisfied with the treatment outcomes and not interested in any alternative treatment at 6MO. In terms of satisfaction with their improvements, most women were ‘completely satisfied’ (20/32, 63%) or ‘somewhat satisfied’ (9/32, 28%). Lastly, participants reported a high satisfaction with their perceived improvement on a Visual Analog Scale, with a median rating of 78% (50-88).

This follow-up study was the first to assess the effects of a telerehabilitation PFMT program and adjunct unsupervised maintenance exercise regimen. Group-based telerehabilitation PFMT led to a clinically significant reduction in leakage episodes at 6MO and maintained improvements in the frequency of leakages, UI severity, UI-related quality of life, bladder function, micturition frequency, and self-efficacy in both managing UI and in performing PFMT exercises.

A 12-week online group-based PFMT program, coupled with an in-person pelvic floor evaluation followed by an unsupervised maintenance exercise regimen, appears to yield sustained clinical benefits six months after the program. A pragmatic, randomized controlled trial is needed to validate these results.

Group-Based vs Individual Pelvic Floor Muscle Training to Treat Urinary Incontinence in Older Women: A Randomized Clinical Trial. JAMA internal medicine. 2020
Group-based pelvic floor muscle training is a more cost-effective approach to treat urinary incontinence in older women: economic analysis of a randomised trial. Journal of Physiotherapy. 2022.
Online Group-based Pelvic Floor Muscle Training for Urinary Incontinence in Older Women: a Pilot Study. International Urogynecology Journal. 2024.

Continence 12S (2024) 101361
DOI: 10.1016/j.cont.2024.101361