Evidence
Alert

Pelvic floor muscle training can be delivered by appropriately trained non-specialists for women with prolapse, research finds

Pelvic Floor Muscle Training (PFMT) is an effective treatment for women with pelvic organ prolapse. However, there are not enough specialist clinicians to deliver it which means access to this treatment is limited. New research finds that other healthcare staff can be successfully trained and supported to deliver PFMT. This could help meet demand for a much-needed service. 

Pelvic floor muscles span the bottom of the pelvis and support the internal organs (womb, bowel, bladder). In pelvic organ prolapse, the muscles are weakened, and one or more internal organs slip down from their normal position. They bulge into the vagina causing pain and discomfort, which has a negative impact on women’s quality of life.

PFMT aims to strengthen the muscles, improve symptoms for women with prolapse and reduce their chances of needing further treatment in the long-term. Two million women in the UK have symptoms of prolapse and could benefit from this training. But there are only about 800 specialist women’s health physiotherapists in the UK able to deliver it.

Researchers explored whether other clinicians such as nurses and general physiotherapists can be trained to deliver PFMT. They found that staff with prior knowledge of women’s health were most confident taking on a new role. They needed adequate training and ongoing support from specialists, other team members and management. Some specialist physiotherapists feared a loss of professional identity; the researchers suggested ways to counter this. 

The findings may be relevant for other parts of the healthcare system in which staff are being asked to expand their existing roles. 

What’s the issue?

Symptoms of pelvic organ prolapse include pain, discomfort, numbness and leaking urine (incontinence).  Pregnancy and childbirth are a leading cause, especially in women who had long, difficult births or who gave birth to large babies or multiples. Being overweight, regular heavy lifting, long-term constipation, surgery to remove the womb (hysterectomy), ageing and the menopause make prolapse more likely.

There are surgical treatments, but these may lead to complications like pain and a need for repeated surgery. 

Pelvic floor muscle training (PFMT) is a physical therapy designed to improve the strength of the muscles and the woman’s control of them. The exercise programme needs to be personalised to each woman. This is usually done by specialist women’s health physiotherapists who are trained to assess prolapse and train women in the exercises. 

Previous work showed that PFMT can improve prolapse symptoms and quality of life in a cost-effective way. It has since been recommended as a treatment for prolapse in NICE guidelines. Yet there are not enough qualified specialist physiotherapists to meet demand. The researchers estimate that for every specialist physiotherapist, there are 2,600 women in need of help.

They set out to find ways of increasing the availability of PFMT for women with prolapse. They wanted to work out whether other NHS healthcare practitioners at different levels and with different clinical backgrounds could successfully deliver PFMT following relevant training. They also addressed the challenges of implementing this change. 

What’s new?

The team worked with five quite different NHS sites across the UK: some urban, some rural,  with a range of resources and varying levels of success in delivering PFMT.  Staff had a mix of skills and experience across the  sites.

Two specialist physiotherapist trainers ran a one-day training session for other physiotherapists (specialist and junior) and women’s health nurses. Each site developed a different model of delivering the PFMT service according  to its resources, location, organisational structure, and staffing. 

The researchers worked in depth with three of the sites to develop a greater understanding of what worked and why. This was done using interviews and focus groups with staff and patients over an 18-month timeframe. 

All sites successfully delivered PFMT. Women’s prolapse symptoms significantly improved both six and 12 months after training, and they were satisfied with the care they received. Newly trained staff were seen as approachable and motivating, and the women reported improvements in their quality of life. 

Women’s access to PFMT increased when:

    • general physiotherapists and nurses had prior experience and relevant knowledge of women’s health, and were receptive to PFMT
    • clinicians referring patients had good awareness of PFMT services and the referral system was straightforward
    • PFMT was a core part of a staff member’s role, rather than an additional task
    • staff had the autonomy to manage their own workload, had dedicated time, admin support and management backing
    • there were fewer specialists already delivering PFMT, for example in rural areas, which led to more readiness to train nurses in the community.

Barriers included a skills gap among some community nurses, who felt the training did not provide the necessary in-depth understanding. Delays between training and working on PFMT could reduce nurses’ confidence. Clarity about the support the nurses needed was sometimes lacking, especially when the physiotherapy team was located separately. 

In addition, some specialists felt their role was under threat and were resistant to training lower grade nurses. 

Why is this important?

PFMT was successfully delivered using different delivery models in a variety of NHS settings. Training non-specialists to deliver PFMT raised fears among some specialists that their professional identity was under threat. These fears were most intense where there were sufficient specialists; they were less pronounced in rural or remote areas, where women’s unmet needs were an overriding concern.  

The researchers therefore suggest a model in which specialist physiotherapists determine a woman’s suitability for PFMT and take on the most complex cases themselves. A core part of their role would be to provide training and support to other clinicians, who would take on the more straightforward cases. This approach could help build a team identity with the shared goal of addressing unmet needs among women. It could counter feelings of threats to professional identity and concerns for care quality. 

The study supports training a range of clinicians to deliver PFMT. Those interested in women’s health or with related prior knowledge, such as continence nurses and non-specialist physiotherapists, are obvious candidates. 

What’s next?

Further roll-out of PFMT delivered by non-specialist clinicians will require adequate training and ongoing support from specialist physiotherapists and managers. 

The researchers would like to see an increase in the use of PFMT as a first-line treatment for prolapse. Improving communication between GPs, primary care and urogynaecology services may help drive this forward. Reviewing the existing pathways leading from primary care to PFMT could also identify areas for improvement. Improving early detection of pelvic organ prolapse and improving awareness and prevention of prolapse are also key areas where more work is needed.

The study implies that other services and health systems could benefit from expanding the role of non-specialist staff.

You may be interested to read

The full paper: Abhyankar P, and others. Implementing pelvic floor muscle training for women with pelvic organ prolapse: a realist evaluation of different delivery modelsBMC Health Services Research 2020;20:910 

The original POPPY trial, which provides evidence for PFMT as the best treatment for pelvic organ prolapse: Hagen S, and others. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet 2014;383:9919 

Related research on pelvic organ prolapse: Abhyankar P, and others. Women’s experiences of receiving care for pelvic organ prolapse: a qualitative study. BMC Women's Health 2019;19:45 

Guidance from the NHS on finding your pelvic floor and how to perform pelvic floor exercises

A PDF guide from the Pelvic Obstetric and Gynaecological Physiotherapy (POGP) charity: The Pelvic Floor Muscles - a Guide for Women

 

Funding: This research was funded by the NIHR Health Services and Delivery Research Programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

In some settings, specialist staff sensed a threat to their professional identity and had concerns about impact on care quality. While this resistance to change and ‘role protection’ is neither new nor surprising, it was interesting that in some sites, these issues were counteracted by the great need for PFMT services. This need acted as a key driver for trying new models of delivery. As a result, rural settings with little access to services or areas which lacked a specialist physiotherapy service were keen to adapt. So, highlighting the need for PFMT services and utilising a triage model to ensure care quality may be ways to counteract the identity concerns among specialists. 

Improving early detection of pelvic organ prolapse and improving awareness and prevention of prolapse are two key areas of work we would like to take forward. Awareness-raising activities should include the recognition of PFMT as a first-line treatment for prolapse. This should extend to healthcare professionals, especially those in primary care. 

We would also like to enable shared decision-making between women and professionals about prolapse treatment, so that women are presented with all available options including PFMT and are supported to choose the treatment that is right for them.

Purva Abhyankar, Lecturer, Faculty of Health Sciences and Sport, University of Stirling

Study participants 

Oh, I’d be 100 % a positive experience, and I’m glad that I had that experience. I’m not glad that I’ve got a prolapse, but I’m glad I’ve had the experience of discussing it with the physios, and being shown how to do the exercises probably better than I would have done them without any intervention by physios. So my experience is a very positive one.

Participant interviewed as part of the study

It was excellent, because the benefits I’ve reaped from it. …. the prolapse is not cured 100 %. But I have, I feel I have quality of life back, I have control over it.

Participant interviewed as part of the study 

Clinician 

This research illustrates the possibility of using a wider skill mix of staff to deliver pelvic floor rehabilitation. 

A training package and ongoing mentoring could enable staff to feel competent at delivering care. There would need to be a national initiative to drive this forward, as otherwise it might just be piecemeal adoption by staff who have an interest. 

Commissioning this care across a wider group of practitioners would result in more women having appropriate access. But it is probably difficult to change roles and usual practice, partly due to clinical pressures on different staff groups and the difficulty in setting up training and continued mentoring. It’s a good concept though, and as staff become more comfortable with interprofessional working or generic skills working, concepts such as this may be adopted more readily. 

A similar strategy may be needed to adequately provide pelvic floor rehabilitation to postnatal women.

Carolyn Lindsay, Lead Senior Physiotherapist, Chesterfield Royal Hospital Foundation Trust