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Guidelines standardise physiotherapy for stress incontinence

Jill Gregson describes the development of guidelines designed to eliminate variations in physiotherapy for women with stress urinary incontinence

In 1996, the Chartered Society of Physiotherapy (CSP) staged several clinical effectiveness 'roadshows' to promote evidence-based practice to its membership. In particular, the development and subsequent implementation of clinical guidelines was highlighted as an effective 'tool' in the evidence-based approach box.

Following the CSP roadshows, an established group of physiotherapy managers in Yorkshire decided to take a proactive, robust but pragmatic approach to the development of evidence-based care.

In consequence, they set up a pan-regional project, with the aim of developing six evidence-based clinical-practice guidelines, one of which was physiotherapy management of stress urinary incontinence.

Armed with enthusiasm and motivation, but complete naivety about the daunting and complicated process ahead, they formed a steering group to coordinate the process.

The process eventually involved participants from 19 NHS trust physiotherapy services within Yorkshire, as well as representatives from the three university physiotherapy education divisions within the geographical area. The participants, who were mainly uniprofessional and totalled approximately 80, were formed into si guideline development groups.

No external funding was received to support the guideline development project. In practice, virtually all the resources and expenses, e.g. staff time, travel, clerical, and stationery, were borne by individual physiotherapy services. The DoH had, at the time, allocated funding for the development of six national physiotherapy guideline projects in certain clinical areas:

	Women's health: management of symphysis pubis dysfunction
	Physiotherapy management of the breathless patient
	Early patient management in the first 72 hours following soft tissue injury
	Acupuncture in pain management
	Injection therapy by physiotherapists
	Early treatment of the hand following trauma or surgery.

The steering group was keen to extend the guideline development process to other areas of clinical practice to promote effective interventions.

As no national guidance was given on which clinical areas should be afforded priority for guideline development outside the DoH-funded ones, the group decided to target areas that it believed were of high resource use, high risk, high cost, and/or subject to widespread variation in physiotherapy intervention.

The clinical areas identified were:

	Physiotherapy management of females aged 16 years or more with stress urinary incontinence.
	Initial physiotherapy evaluation and subsequent management of patients with whiplash injury of the cervical spine.
	Selection of vascular lower limb amputees for prosthetic rehabilitation.
	Physiotherapy approach to adults undergoing upper abdominal surgery.
	Physiotherapy assessment of balance in people aged 65 years or more.

The steering group decided to base the project methodology and process on those described by Eccles et al,¹ from their experiences in the North of England Evidence-based Guideline Development Project, as there was a dearth of descriptions of the development of valid guidelines at that time.

The group also decided to adopt a similar guideline presentation style and format to that used by Eccles et al in their guideline The Primary Care Management of Asthma in Adults.²

Consequently, all of the six guideline development groups were working to a shared methodology and process and presentation style.

The literature search

The aim of the search was to identify papers in the published literature that provided evidence relevant to the topic of the guideline.

Key words were established, and searches were carried out through 14 databases including, MEDLINE, CINAHL, EMBASE, AMED and the Cochrane Database of Systematic Reviews.

The literature search was undertaken by the development group members, using a set of methodological criteria. Each development group member had also received training in critical appraisal skills.

The evidence sifted from the literature was graded according to the Canadian Task Force classification:³

I	Based on well-designed randomised controlled trials, meta-analysis or systematic review
II	Based on well-designed cohort or case-control studies
III	Based on uncontrolled studies or consensus

In light of the evidence found, the group developed recommendations for practice through vigorous group discussion. Where evidence from the literature was not available, consensus opinion from the group was accepted.

Review process

On completion of a first draft, the guideline document was sent to a multidisciplinary group of external reviewers, who were asked for comments on the guideline's clarity, validity and comprehensiveness.

The guideline is currently with the CSP awaiting a decision regarding national endorsement.

Why target stress urinary incontinence?

Urinary incontinence is very common in women, and although it can occur at any age its prevalence increases with advancing years. Genuine stress incontinence is the most common form of urinary incontinence in women.^4,5

Incontinence can have a devastating effect on the lives of sufferers and their families, and can impose an enormous burden on the nation, in terms of both emotional and financial costs. Among adult women with urinary incontinence:

	60% avoid going away from home
	50% feel odd and different from others
	45% avoid public transport
	50% report avoiding sexual activity through fear of incontinence.6

A recent briefing paper by the Royal College of Nursing (RCN, 1997)⁷ investigated the cost of incontinence depending on alternative referral pathways, and whether patients were living at home, in hospital or in residential care. The study found that home care costs 35p per day (£2.45 per week), acute hospitalization costs £784 per week, and residential care costs £300 per week.

Recommendations for treatment

While it is widely accepted that the most effective treatment of severe or persistent genuine stress incontinence is surgery, the first approach for the majority of women is usually conservative therapy,pusing a number of modalities, including pelvic floor exercises, electrical stimulation, biofeedback, and cones.⁸

These treatments are readily available and relatively inexpensive, have very few complications, do not compromise future surgery, and should be an option for all incontinent women.⁸

Scope of the guideline

The area covered by the guideline is physiotherapy assessment and conservative treatment of stress urinary incontinence.

Treatment modalities include:

	Pelvic floor exercises (PFE)
	Neuromuscular electrical stimulation
	Biofeedback
	Weighted vaginal cones.

Figure 1 (below) shows a summary flowchart of the guideline. The full guideline document provides detailed recommendations for practice at each stage in the summary flowchart, and explicitly states the quality of evidence supporting the recommendations.

Figure 1: Summary flowchart of the Yorkshire guidelines on physiotherapy assessment and conservative treatent of stress urinary incontinence in women

Decisions to adopt any particular recommendation must be made by the individual practitioner in the light of available resources and the individual patient's circumstances.

Guideline dissemination and implementation

The guideline aims to eliminate currently perceived variations in physiotherapy practice for this client group. If we can achieve this, then assessment of benefit should be more measurable.

It is intended to disseminate the guideline to every physiotherapy service within Yorkshire.

The implementation stage is recognised as being as complicated as the development stage. To help overcome some of the perceived barriers to implementation, the steering group is advocating:

	An educational component, highlighting the content of the guideline to practitioners through seminars and roadshows, possibly utilising local opinion leaders.
	A compliance component, which seeks to encourage practitioners to refer to and comply with the guideline at relevant patient interventions, e.g. via revised patient documentation, desktop reminders, and computer interactive systems.

Shared specific patient documentation would allow audit and evaluation across physiotherapy units.

Dissemination and implementation in a wider sphere, e.g. nationally, will be dependent upon professional body endorsement and subsequent support.

The whole development process has taken 2 years. Guideline develoment, when undertaken in a comprehensive, robust and rigorous fashion, is a difficult and complicated process requiring considerable resources. We believe, however, that meaningful guidelines can be developed on a regional basis, as this provides access to a greater pool of skills in many areas than exist at a purely local level.

The learning curve has been steep, but the benefits and advantages have outweighed the problems encountered. For example, we now have groups of staff across the region who are better able and more confident in literature appraisal, in understanding literature search strategies, in debating reasons for certain interventions, and in generally being more aware of clinical effectiveness and the issues around evidence-based care.

References

1. Eccles M, Clapp Z, Grimshaw J et al. Developing valid guidelines: methodological and procedural issues from the North of England Evidence-Based Guideline Development Project. Q Health Care 1996; 5: 44-50.
2. Eccles M, Clapp Z, Grimshaw J et al. The Primary Care Management of Asthma in Adults. North of England Evidence-Based Guideline Development Project. University of Newcastle upon Tyne, 1996.
3. Canadian Task Force. Can Med Assoc J 1970; 121: 1193-254.
4. Drife J, Milton P, Stanton S et al (Eds). Micturition. London: Springer-Verlag, 1990.
5. Shaw R, Scoutter W, Stanton S (Eds). Gynaecology. Edinburgh: Churchill Livingstone, 1992.
6. Norton P, MacDonald L, Sedgwick P et al. Distress and delay associated with urinary incontinence, frequency and urgency in women. Br Med J 1988; 297: 1187-9.
7. Royal College of Nursing. The Cost of Incontinence. London: RCN, 1997.
8. Royal College of Physicians. Incontinence: Causes, Management and Provision of Services. London: RCP, 1995: 1-5.

Jill Gregson is physiotherapy manager at Bradford Hospitals NHS Trust and a member of the guidelines steering group

Guidelines in Practice, December 1999, Volume 2 © 1999 further information |