Adherence to Pelvic Floor Physical Therapy During COVID-19: A Retrospective Study

Abstract

COVID-19 introduced widespread challenges in healthcare access and was demonstrated to be a significant stressor for patients with pelvic floor dysfunction (PFD). Pelvic Floor Physical Therapy (PFPT) is a first line behavioral modification to address PFD. The impact of COVID-19 on PFPT adherence rates in a urogynecologic population is unknown; therefore, a retrospective chart review was conducted looking at “pre-pandemic” (referring to before 1 March 2020) and “pandemic” (referring to after 1 March 2020) cohorts. A total of 173 women met the inclusion criteria (93 pre-pandemic vs. 80 pandemic). The PFPT adherence rates were similar between the pre-pandemic and pandemic groups (20.0% vs. 18.8%, p = 0.85). Patient-reported barriers to initiation included insurance coverage, transportation, and time commitment. When looking for clinical correlates associated with non-adherence, patients who utilized an internal referral to a hospital-associated PFPT facility were 4.9-fold more likely to adhere to PFPT for PFD (95% confidence interval: 1.31–18.23, p = 0.018). While COVID-19 was not identified as a barrier to PFPT adherence, identifying barriers preventing patients from attending PFPT remains an area for improvement. Increasing the utilization of an internal referral system to a hospital-associated PFPT facility may be an effective solution for increasing patient adherence.

1. Introduction

In the wake of the Coronavirus Disease 2019 (COVID-19) pandemic, barriers to accessing care for many people were uncovered. With the restrictions, lockdowns, and quarantining of individuals immediately at the start of the pandemic, many people were not able to seek care for various medical conditions across all specialties. Notable patterns in care avoidance occurred with Sprinter et al. identifying older individuals, females, unemployed people, and people in poorer health as those with the highest rates of healthcare avoidance [1].

Pelvic floor dysfunction (PFD) includes a wide variety of urogynecologic complaints affecting up to 46% of women world-wide, with the literature demonstrating that COVID-19 caused significant psychological distress, negatively impacting the quality of life for patients suffering from these disorders during the pandemic [2]. A literature review of management recommendations for urogynecology patients during the COVID-19 pandemic concluded that behavioral therapies should still be recommended as first line treatment [3]. Pelvic Floor Physical Therapy (PFPT) is one such behavioral therapy that has demonstrated significant efficacy in improving PFD symptoms in women [4,5,6,7,8]. Additionally, a study from the UK demonstrated that routine physical exercise during the COVID-19 pandemic correlated with improved mental wellbeing, further highlighting the importance of physical therapy treatments during the pandemic [9].

PFPT is a general term for the instruction of pelvic muscle strengthening, relaxation, and coordination exercises by a trained physical therapist. However, adherence to PFPT is low, with less than 50% of those referred for PFPT attending their first visits [10]. Advancements in delivering PFPT via telehealth was one consideration to address this barrier during the COVID-19 pandemic and a recent systematic literature review found that patients who underwent PFPT via telehealth had similar improvement in their incontinence symptoms compared to face-to-face treatment during the pandemic [11,12,13]. However, notable limitations to the use of telehealth PFPT include the lack of infrastructure within the physical therapy offices, patient access to consistent internet or cellular service, patient comfort with using technology independently, and the inability for the assessment of women’s capacity to contract their pelvic floor muscles correctly when using telehealth [14].

The urogynecology office treats a wide age range of women with PFD but the average age is reported to be between 51 and 63 years of age, the average age of the patients completing PFPT via telehealth is reported to be around 43 years of age; therefore, the aim of our study was to analyze adherence to PFPT during the COVID-19 pandemic in a urogynecology office with a secondary aim of identifying barriers to the initiation of PFPT care.

2. Materials and Methods

After institutional review board approval (n°: Pro2022-0530), the electronic medical records of all female patients aged greater than 18 years who were seen by a urogynecologist and given a referral for Pelvic Floor Physical Therapy between March 2018 and March 2022 at a single academic institute were retrospectively reviewed. Referrals given prior to 1st March 2020 were designated as “pre-pandemic”, while referrals given on and after 1st March 2020 were designated as “pandemic”.

Demographic information was extracted from the medical records, including age, BMI, parity, insurance type, self-reported race/ethnicity, home zip code, and COVID-19 vaccination status. Clinical notes were reviewed in detail to determine the reason for PFPT referral and any prior urogynecologic therapies received. The electronic medical records were examined to determine the rate of initiation of PFPT, number of sessions attended, if the patient completed PFPT, and any subjective improvement reported. In addition, the utilization of the hospital-associated PFPT records were assessed and patients utilizing this system were categorized as an internal referral system. If the patient reported utilizing a PFPT outside of the hospital system (i.e., private office or rehab center), this was deemed an external referral.

Non-adherence was defined as failure to initiate PFPT within one year from the date of referral. To probe the reasons behind the failure of PFPT initiation, patient reported barriers were tracked through qualitative interviewing as reported in the electronic medical record. This study was powered to detect a 50% difference in treatment non-adherence. Driving distance was estimated from the distance between the patient’s home zip codes to the zip codes of the PFPT locations. Calculations were carried out using Grok 3 (xAi, 2023). Means and standard deviations were reported for continuous variables and proportions for nominal variables. Comparisons were performed using Fisher exact test or Chi2 test for nominal variables and Mann–Whitney test for continuous variables. Univariate logistic regression analyses were performed to look for predictive factors of non-adherence. Statistical analyses were performed using JMP v.16.2 software (SAS Institute Inc, Cary, NC, USA). All tests were two-sided with a significance level set at p < 0.05.

3. Results

Among the 173 patients who met the inclusion criteria for the analysis, 80 were categorized as pre-pandemic and 93 as pandemic. The pre-pandemic group had a median age of 63, median BMI of 27, and median parity of 2; the pandemic group had a median age of 60, median BMI of 28, and median parity of 2. The majority of both groups were insured by private insurance (67.5% and 66.6%), self-identified as white/non-Hispanic in race/ethnicity (85% and 88.2%), and vaccinated against COVID-19 (62.5% and 66.6%). Between the two groups, the patients were similar in age (p = 0.12), race (p = 0.89), BMI (p = 0.64), parity (p = 0.96), insurance type (p = 0.43), driving distance to PFPT center (p = 0.65), and COVID-19 vaccination status (p = 0.57) (

Table 1. Patient characteristics.

	Referral Given Prior to COVID-19 Pandemic (n = 80)	Referral Given During COVID-19 Pandemic (n = 93)	p-Value
Age (y), median, IQR	63 (23–97)	60 (23–87)	0.12
BMI, median	27 +/− 5.4	28 +/− 5.3	0.24
Parity, n, IQR	2 (0–6)	2 (0–6)	0.39
Insurance Type n, (%) Public Private	26 (32.5) 54 (67.5)	31 (33.3) 62 (66.6)	0.91
Race/Ethnicity n, (%) White Asian/Indian Black Hispanic Unspecified	68 (85) 2 (2.5) 3 (3.8) 5 (6.3) 3 (3.8)	82 (88.2) 4 (4.3) 3 (3.2) 2 (2.2) 1 (1.2)	0.47
COVID Vaccination Status, n, (%) Vaccinated Not Vaccinated	50 (62.5) 30 (37.5)	62 (66.6) 31 (33.3)	0.57
Average Driving Distance (Mlies)	18.3 +/− 25.5	19.9 +/− 29.7	0.65
Reason for PFPT Referral, n, (%) Stress Incontinence Urge Incontinence Mixed Incontinence Overactive Bladder Symptoms Pelvic Organ Prolapse Pelvic Pain >1 PFD	14 (17.5) 5 (6.3) 14 (17.5) 13 (16.3) 13 (16.3) 11 (13.8) 10 (12.5)	11 (11.8) 2 (2.2) 15 (16.1) 22 (23.7) 11 (11.8) 8 (8.6) 24 (25.8)	0.15
Prior Therapy, n, (%) None Behavioral Therapy Pessary Medication Intradetrusor Botulinum Toxin Peripheral Tibial Never Stimulation Midurethral Sling Prolapse Repair	53 (66.3) 5 (6.3) 6 (7.5) 9 (11.3) 0 0 2 (2.5) 5 (6.3)	68 (73.1) 3 (3.2) 3 (3.2) 13 (14) 1 (1.1) 1 (1.1) 1 (1.1) 7 (7.5)	0.64

). There were no statistically significant differences in urogynecologic reasons for PFPT referral between the two groups. In addition, 66.3% and 73.1% of the patients in the pre-pandemic group and pandemic group, respectively, had not received any prior urogynecologic therapies.

There were no statistical differences in referral patterns between the pre-pandemic and pandemic groups with the mean timing of referral for PFPT given between the first and second visit (p = 0.3) (

Table 2. Pelvic Floor Physical Therapy referral patterns.

	Referral Given Prior to COVID-19 Pandemic (n = 80)	Referral Given During COVID-19 Pandemic (n = 93)	p-Value
Visit # 1st referral given, median	1.6 +/− 2.0	2.0 +/− 2.9	0.3
Total # of referrals given, median	1.0 +/− 0.5	1.0 +/− 0.2	1.0
Initiated PFPT (%)	20.0	18.8	0.85
# of PFPT sessions attended, median	7.5 +/− 5.6	7.0 +/− 3.7	0.48
Completed PFPT (%)	74	70	0.65
In-network referrals, n (%) Out-of-network referrals, n (%)	58 (73) 22 (28)	75 (81) 18 (19)	0.21

). Adherence to initiation rate for PFPT were similar between the pre-pandemic and pandemic groups (20.0% vs. 18.8%, p = 0.85). The medians of the total sessions attended were also similar between the pre-pandemic and pandemic groups (7.5 vs. 7.0, p = 0.48). After attending the first PFPT session, 74% and 70% of patients completed the program, respectively. Of the patients who completed PFPT, 72% and 73% reported a subjective improvement in PFD symptoms among the pre-pandemic and pandemic groups, respectively.

Of the 114 patients who did not initiate PFPT, 6% of the patients reported a reliable form of transportation as their barrier to initiation; 3% reported issues with cost/insurance coverage; 4% reported the required time commitment precluded them from initiating; and the remaining 84% of patients either failed to identify a barrier or chose not to respond. In regard to COVID-19, only 6% of patients reported fear of exposure to COVID-19 as the barrier to initiation or continuation of PFPT.

Overall, the utilization of a telehealth PFPT program by this population during the COVID-19 pandemic was low, with 3% of patients pursuing this option. When looking for clinical correlates associated with non-adherence, only referrals to an external PFPT program were statistically significant (92.9% vs. 75.7%, p = 0.002). After adjusting for age, BMI, parity, insurance, driving distance, and race/ethnicity, patients with an internal referral utilizing our hospital-associated PFPT facility were 4.9-fold more likely to adhere to PFPT for PFD (95% confidence interval: 1.31–18.23, p = 0.018).

4. Discussion

Our study aimed to investigate the effect of the COVID-19 pandemic on the adherence rate to PFPT for PFD. Contrary to our initial hypothesis, there was no statistically significant difference in the adherence rate before or after the COVID-19 pandemic. After adjusting for multiple possible confounders, the only statistically significant finding that was associated with an increase in adherence was the use of an internal referral system to a hospital-associated PFPT facility. Common barriers to the initiation of PFPT identified in both groups of patients were financial concerns, reliable transportation, and time commitment, which are consistent with prior studies [15,16]. The lack of insurance coverage has been known as a major barrier to healthcare in the United States with initiatives and policy changes continually addressed within the healthcare system. A multifaceted approach including policy reform and expanded access to affordable care is still in need.

Our findings revealed an overall adherence rate of 19.4%, which is consistent with the PFPT adherence rate published in the literature [15]. Brown et al., demonstrated that a PFPT consultation at the time of initial urogynecologic evaluation improved the attendance of the initial PFPT appointment, but did not improve the completion rates [15]. While our study had similar referral patterns to Brown et al., we identified that select, motivated patients who initiated treatment had high compliance rates and reported subjective improvement for PFD symptoms. These findings suggest that targeted interventions aimed at encouraging patients to initiate treatment could be effective in improving adherence rates.

In response to the COVID-19 pandemic, many major healthcare organizations encouraged the use of telehealth systems to provide safe and timely care for patients without increasing the risk of COVID-19 exposure [17,18]. Such change was brought into PFPT, since it can address not only the accessibility barrier during the pandemic, but also the concern of urinary and fecal incontinence, which may discourage patients from leaving their homes for attending in-person PFPT [19]. Harr et al. assessed the change in attendance of telehealth PFPT sessions versus in-person visits before and during the pandemic and found that the attendance rate was higher in telehealth appointments than in-person ones (p < 0.001) with no association with primary diagnoses or proximity based on zip code [20]. In contrast, our study found that despite the availability of telehealth PFPT, utilization at our facility was low, with only 3% of patients choosing to pursue this method. A notable difference was that only the hospital-associated PFPT office offered this as an option and therefore that may have been the cause for its limited utilization. Additionally, the population in our study had a mean average age of 60–63,which is considerably older than the other reported studies looking at the utilization of telehealth PFPT. This may have contributed to the low telehealth PFPT utilization.

One limitation of our study is that we did not assess all potential factors that may have influenced adherence to PFPT, including but not limited to income levels, socioeconomic status, healthcare literacy, language fluency, etc. Our study is also a retrospective analysis that included the review of non-standardized qualitative interviews with the patients, which were then documented in the medical records. This may have allowed for patient recall bias to have impacted the study. Additionally, a provider may have chosen not to document one or more reasons for non-initiation of PFPT. This review also relied on patient subjective improvement of various PFD. It may be that if the study is performed on a population with one specific PFD symptom, then there may be a difference in adherence rates. Notability, this population is a relatively small sample size in addition to the study being based at a single academic institution. Our patient population consists largely of non-Hispanic white women with private insurance (85%), which may limit its generalizability to all patients, as the barriers in this patient population may vary widely from those in a different socioeconomic setting. A multi-institutional prospective analysis on a socioeconomic and ethnically diverse patient population is needed to better generalize findings for a larger population.

Overall, our study contributes to the understanding of general patient adherence and initiation to PFPT for PFD. The COVID-19 pandemic led to significant disruption in health service delivery and allowed for exposure of existing gaps in the health system as a whole [17]. From our study of a total of 173 patients who received the PFPT referrals over a span of four years around the COVID-19 pandemic, we found that there were no significant differences when comparing adherence to PFPT before or during the pandemic. The overall adherence rate in our studied population was 19.4%, which is consistent with the existing literature. Importantly, patients who attended at least one visit were likely to complete treatment and report subjective improvement. The utilization of an internal referral system to a hospital-associated PFPT facility, increased patient adherence to initiation and completion of PFPT. While expanding insurance coverage remains the mainstay of improving healthcare access, we propose that urogynecology offices explore the possibility of forming relationships with a hospital-associated PFPT facility and expand telehealth PFPT awareness and utilization as potential solutions to improve PFPT adherence rates in patients with PFD.