4. Discussion
MINOR, CONTRACTION, CONTRACTIONS
This pilot feasibility study is the first to investigate the feasibility of an online group-based PFMT program. The study showed that the teleGROUP program was feasible from the participant perspective, with high attendance at the online classes, high adherence to the home exercises, infrequent and minor side effects resolving quickly, low attrition throughout the 12-week program, high satisfaction with the program and good perceived usability of the online program. In addition, this study showed good feasibility from the clinician perspective, with high acceptability from the evaluating physiotherapists and relatively good fidelity to the original program guidelines from the physiotherapist leading the program, despite time constraints. Compared to the original in-person version of the program, teleGROUP showed a similar attendance rate (95% vs. 95.2% in GROUP and teleGROUP, respectively) and lower attrition throughout the program (7% vs. 3% during the program and 6% for the overall study) [Throughout the program, the clinical expertise of the specialized physiotherapists played a key role in ensuring adequate treatment delivery, regardless of the online or group format. First, during the initial in-person evaluation, the physiotherapists taught participants to contract their PFMs. They were able to guide the participating women so that they could achieve an adequate PFM contraction by overcoming perineal inversion (i.e., straining and depressing the pelvic floor rather than executing the expected inward lift and squeeze), compensations (e.g., contraction of other muscles, such as abdominal muscles, gluteal muscles, adductors, diaphragm) or difficulty relaxing their PFM. These challenges are similar to those observed in other studies, where between 17% and 43% of women initially strained, pushed or used a Valsalva maneuver when attempting to contract their PFMs [Additionally, when facing time constraints during the 12-week program, the physiotherapist leading the teleGROUP sessions made some decisions that were informed by clinical expertise and experience. This clinical decision process was reflected in the fidelity findings: Besides the individual exchange and the educational session, the physiotherapist prioritized the four main PFM exercises constituting the core elements of the program over the other exercises from the program. Comparatively, in the GROUP trial, the per protocol fidelity percentage was higher overall (77.9% of the content for the functional exercise of the dance activity and 79.8% of the content for the transverse abdominal contractions (unpublished data), compared to 31.2% and 12.5%, respectively, in the teleGROUP program). Yet, the disparities between the in-person and online versions of the program tend to disappear when considering the core elements of the program, notably, the four main PFM exercises. Indeed, the fidelity was relatively similar for these 4 PFM exercises, with 90.7%, 96.2%, 100.0% and 98.7% for each exercise (unpublished data), compared to 96.7%, 97.0%, 98.4% and 100.0% in the GROUP and teleGROUP programs, respectively. Moreover, the physiotherapist leading the teleGROUP program limited the position changes during the sessions to avoid multiple camera angle adjustments by both the physiotherapist and the participating women and to reduce the time spent correcting posture. Additional time was still needed to complete the treatment sessions due to the time spent in individual exchanges, particularly when dealing with a high number of participants. As adherence to the PFM exercise program constitutes the cornerstone of successful UI treatment [The findings of the present study represent an important first step in guiding the upcoming research steps towards the implementation of group-based PFMT telerehabilitation programs in various healthcare settings. This format provides a safe UI treatment option during pandemic periods or in any other situation that presents a health risk (e.g., winter storm). An online option could also increase the accessibility of continence care for women living in rural or remote areas, where pelvic floor rehabilitation services are unavailable or scarce. It could also be an additional asset for any woman who cannot attend in-person treatment due to her living situation (i.e., caring for someone at home), transportation difficulties or any other personal reason. This study also presents some limitations. As this was a feasibility study on an innovative treatment approach, a relatively small sample size was included, and the intervention was delivered from a single institution, limiting the generalizability of the findings. However, pilot studies constitute an important part of the research process [