3.1 Study Inclusion
The published studies were between 2016 and 2020 and were undertaken in Sweden, Canada, Brazil, and China. Of the four trials, three were complete trials, and one a two-year follow-up post completion of an RCT. A variety of primary and secondary outcomes were assessed across the trials. Outcomes documented in the trials included symptom severity, QOL and adherence to PFMT, bladder neck function, sexual activity, cure rates and use of incontinence products. Three studies (6-8) included symptom severity and adherence as primary outcomes. One study (9) continued with the same outcomes from the Asklund, Nyström (7) trial as they conducted the two year follow up. Each study clearly defined the primary and secondary outcomes and time to follow-up varied across the studies.
3.2 Quality of included studies
The JBI quality appraisal tool, a 13-point checklist for randomised controlled trials was used to assess the quality of the four studies (Appendix 2). The methodological quality of the studies was assessed based on methods of randomisation, allocation concealment, blinding, outcomes, statistical analysis, and loss to follow-up. True randomisation, allocation concealment and similar baseline were unanimous across the studies except for the two-year follow-up trial. Blinding was true amongst all participants in the studies conducted by two studies (6, 7). Blinding for participants was declared not feasible by two studies (8, 9). Those delivering treatments were blinded in only one study (8). True blinding of outcome assessors did not occur in the four studies.
3.3 Review Findings
The findings synthesised into three categories, appendix 3 presents an overview of the study characteristics.
Adherence to PFMT using a mobile application and perceived value of using a mobile application
Four studies generated this findings (6-9). These four studies determined the success of adherence to PFMT using a mobile application by evaluating self-reporting measures, urinary symptoms, app utilisation and self-efficacy . The adherence rate was higher in the mobile application group and this was evident after one-two months of pelvic floor exercise, reflected in P<0.001. Self-reported adherence in the mobile group showed better results during treatment, also reflected by P<0.001 (6). Asklund et al (2016) found a higher adherence rate in the mobile application group, they report that 41% performed pelvic floor exercises daily and this was vastly different to the control group who recorded a 3.3% adherence rate to daily pelvic floor exercise. Hoffman et al (2017) followed up the original Asklund et al (2016) study and of the 46 women who participated in this follow-up, all 46 women had downloaded and kept the mobile application and 17.4% were still using it two years later.
Frequent users who intend to use mobile applications on a regular basis, indicated higher PFMT adherence compared to those performing stand-alone exercises… “based on our results women who used it not only exercised more than the other group, based on exercise sections duration but also felt more committed to exercising”( Arajou et al., 2019; p.6). Also, people who used mobile applications in the short term were satisfied about the outcome: “with the present study we have shown the app treatment to be effective in the short term” (Asklund et al., 2016; p.1375). The high-level adherence rate of PFMT using an application resulted in participants suffering less from pelvic floor injury, less bladder neck descent and improved pelvic floor strength: “participants receiving the app-based audio guidance indicated more positive effect to 6 months postpartum” (Wang et al.,2020; p. 7). Patients who used mobile applications to undertake exercise reported positive aspects of the application: “the reminder notes were important to exercise adherence and preferred to continue using the said feature” (Arajou et al., 2019; p.6).
QOL
Findings from three studies, Arajou et al (2019), Asklund et al (2016) and Hoffman et al (2017) contributed to this synthesised finding. QOL measures are an estimation of wellbeing which can be assessed by measuring improvements in areas like healthcare and are based on an individual’s perception and expectations of treatment outcomes. In the app group Asklund et al (2016) presented a mean score reduction in QOL scores 4.8, 95% CI: 3.4-6.2 and the control group did not have a mean score reduction in QOL. QOL was measured among other outcomes and the app group did show improvement with P values = 0.003 Araujo et al (2019). It is well established that the physical, psychological, and sociological effects of UC affect QOL amongst diverse patient groups and mobile applications easily provide access to life changing treatments with recurrent users … “experiencing fewer symptoms and reporting a better QOL” (Asklund et al., 2016; p.1373). Discovering long term benefits of PFMT using an application has improved QOL in mobile users has been a success in long term studies … “our study yielded promising long-term results in terms of a condition that can severely affect QOL” (Hoffman et al., 2017; p.1185).
Symptom Improvement
Findings from four studies (Arajou et al (2019), Asklund et al (2016), Hoffman et al (2017) & Wang et al (2020) contribute the synthesised finding of reduction in symptoms. To benefit from a treatment program delivered by a mobile application is outstanding and has been acknowledged as a successful outcome in these recent studies, with participants reporting positive results using an application for PFMT to reduce UC. Symptom reduction measured by validated assessment tools and methods provides valuable data and true insight into the condition “people experience greater improvement in symptom severity with a mean reduction in ICIQ scores” (Asklund et al., 2016; p.1372) and “we found that PFMT improves symptoms of UC, according to validated questionnaires” (Arajou et al., 2019; p.6). Furthermore, the cost and burden associated with continence aids is high and patients frequently ask during consultation when they will be able to cease using pads (Coyne et al 2014). “Outcome measurements at follow-up determined 56% of the app group as no leakage or>50% fewer leakage episodes than at baseline” (Asklund et al., 2016; p.1372). Physically, a strong pelvic floor can improve and maintain continence as well as delay surgical intervention and the associated risks of major surgery (Giarenis & Robinson, 2014). Pelvic floor strength and less bladder neck descent has been noted in frequent users of mobile applications for pelvic floor muscle training: “participants had significant improvements in symptom severity after 3 months” (Wang et al., 2020; p.5), reiterating the practicality of an accessible PFMT program and the importance of conservative management of UC.