rehab+incontinence

8/22/2019 Rehab+Incontinence

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Grand RoundsElliot J. Roth, MD, Editor

Urinary Incontinence After Stroke: Does

Rehabilitation Make a Difference? ASystematic Review of the Effectiveness of

Behavioral TherapyChantale Dumoulin, Nicol Korner-Bitensky, and Cara Tannenbaum

Top Stroke Rehabil 2005;12(3):6676 2005 Thomas Land Publishers, Inc.www.thomasland.com

66

Chantale Dumoulin, PT, PhD, is a post-doctoral fellow, School

of Physical and Occupational Therapy, McGill University, Center

for Interdisciplinary Research in Rehabilitation of GreaterMontreal (CRIR), Montreal, Quebec.

Nicol Korner-Bitensky, OT, PhD, is Associate Professor,

School of Physical and Occupational Therapy, Center forInterdisciplinary Research in Rehabilitation of Greater Montreal(CRIR), McGill University, Montreal, Quebec.

Cara Tannenbaum, MD, MSc, is Assistant Professor, Faculty

of Medicine, University of Montreal, and Director of the GeriatricIncontinence Clinic at the McGill University Health Centre,

Montreal, Quebec.

This study uses a comprehensive review of the literature to assess the scientific evidence for the effectiveness of behavioraltherapies to treat urinary incontinence (UI) post stroke. Evidence for the different behavioral therapies was criticallyappraised to achieve a level of evidence based on Foleys classification of levels of evidence. Only four randomized clinicaltrials (RCTs), one cohort study, and recommendations from three clinical practice guidelines were found. There is limitedevidence that bladder retraining with urge suppression in combination with pelvic floor exercises results in reduction of UIin male individuals with stroke. Further research is urgently needed to elucidate clinical recommendations about theefficacy of behavioral approaches. Key words: bladder neurogenic, bladder training, cerebrovascular accident, pelvic floorexercises, polyuria, prompted voiding, timed voiding, urinary incontinence, urinary retention, urination disorder

An often forgotten but serious consequenceof stroke is new onset urinary incontinence(UI). The prevalence of UI post stroke

ranges from 37% to 79% in the days and weeksimmediately following the event.1,2 Upon

admission to the rehabilitation facility, 26% to44% of individuals referred for strokerehabilitation programs report persistent UI.3

Although the prevalence continues to decreaseover time,2,4,5 as many as one third of individualsare still incontinent 1 year post stroke.2,6

UI is a strong predictor of functional recovery.In a population-based cohort study, Taub et al.7

found that incontinence in first-time stroke survi-vors younger than 75 years was the best singlepredictor of disability at 3 months, with a sensitiv-

ity of 60% and specificity of 78%. Discharge desti-nation post stroke is also related to incontinence.8

Ween and colleagues9 found that only 46% of 145incontinent individuals with stroke returned homeafter rehabilitation hospitalization compared to79% of 278 who were continent. UI has a knownassociation with low self-esteem, social isolation,and depression.10 Medically, UI predisposes indi-viduals to urinary tract infections, nephritis, fungaldermatitis, and an increased risk for falls.311 For

persons requiring rehabilitation therapy, UI affectstherapy time, concentration, and participation intreatment.12 Addressing UI post stroke is thereforean integral aspect of the post stroke rehabilitationprocess.

There are multiple etiologies for UI post stroke.Symptoms reflect the underlying cause. UI mayresult from infarction or cerebral edema affectingcentral micturition pathways. When frontal lobedamage occurs, symptoms include frequency, ur-


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Urinary Incontinence After Stroke 67

gency, incontinence, and possibly nocturia.13 Withstrokes affecting the brainstem, individuals com-monly experience hesitancy, bladder dyssynergia,and urinary retention due to the inability toachieve simultaneous bladder contraction and ure-thral sphincter relaxation to empty the bladder in acoordinated and timely fashion.13 Disruption of theneuromicturition pathways has also been shown toresult in bladder hyperreflexia and urgency incon-tinence.14Alternatively, stress UI with urine leak-age may be exacerbated by frequent coughing fromdysphagia. Impairments of consciousness or ofmotor, sensory, cognitive, or language functioncan also affect toileting, despite normal bladderfunction.14 The presence of preexisting peripheral

neuropathies from diabetes may result in bladderhyporeflexia and overflow incontinence.14 Otherimportant contributing factors include thepatients medications (antihypertensives, diuret-ics)314; the presence of depression,15 constipa-tion,15 or environmental factors that impedetoileting15; or preexisting UI.25 In most cases, acombination of factors contributes to UI poststroke,1 making the treatment more challenging.

Management of UI takes many forms includingbehavioral, pharmacological, surgical, and sup-

portive devices.16 The present systematic reviewfocuses on the behavioral management of UI inindividuals who have experienced a stroke. Behav-ioral management in this group includes timedvoiding, prompted voiding, bladder retrainingwith urge suppression, and pelvic floor muscleexercises.3 Behavioral techniques are recom-mended as the first-line treatment for UI in adultsby the Agency for Health Care Policy and ResearchClinical Practice Guidelines16,17 and by the 2ndInternational Consultation on Incontinence.18

The objective of this systematic and comprehen-sive review is to assess the scientific evidence forthe effectiveness of various behavioral therapies forthe treatment of UI post stroke, specifically, timedvoiding, prompted voiding, bladder retrainingwith urge suppression, and pelvic floor muscleexercises. The following questions were posed us-ing the PICO (Population, Intervention, Control,and Outcome) concept19:

In the adult stroke population, is a behavioral

intervention more effective than no interven-tion or placebo/alternative intervention in themanagement of UI?

In the adult stroke population, is a combina-tion of behavioral interventions more effectivethan no intervention or placebo/alternativeintervention in the management of UI?

Research evidence was combined in these differ-ent areas to achieve a level of evidence usingFoleys levels of evidence.20 These are based on theoriginal Sacketts levels of evidence21 but are modi-fied to account for physiotherapy evidence data-base (PEDro) scoring. Five levels of evidence wereconsidered: strong, moderate, limited, consensus,

and conflicting (Appendix A).20

Method

Systematic review of the literature

A comprehensive review of the English-lan-guage medical literature was performed coveringthe period from January 1966 to July 2004 usingthe electronic MEDLINE database and coveringthe period from January 1982 to July 2004 with

the CINAHL database to search for articles relatingto UI in individuals with stroke. The following keyterms were used: urination disorder,bladder neu-rogenic, and cerebrovascular accident. In a firstsearch, the term urination disorder, which ex-plodes to polyuria, urinary incontinence, and uri-nary retention, was used together with cerebrovas-cular accident. In the second search, the termbladder neurogenic was used together with cere-brovascular accident. In addition, a comprehen-sive review of the English-language literature was

performed covering the period from January 1980to July 2004 using EMBASE with the following keyterms: micturition disorder, bladder neurogenicand cerebrovascular accident.In a first search, theterm micturition disorder, which explodes to poly-uria, urinary incontinence, and urinary retention,was used together with cerebrovascular accident.In the second search, the term bladder neurogenicwas used together with cerebrovascular accident.

All randomized clinical trials (RCTs) and cohortstudies related to behavioral treatment were con-


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68 TOPICSIN STROKE REHABILITATION/SUMMER2005

sidered for inclusion. In addition, the referencelists of retrieved articles were reviewed to identityadditional references that may not have beenfound in the preliminary search.

Next, two evidence-based databases, theCochrane database of systematic review22 andPEDro23 were explored for systematic reviews andRCTs using stroke and incontinence as key terms.In addition, the Cochrane central register of con-trolled trials (CENTRAL)24 was searched for RCTsusing the same key terms. All major authors work-ing in the area of UI in individuals with strokewere also sought in citation indexes using the ISI

Web of Science database to verify that all publica-tions relevant to UI in individuals with stroke were

obtained.25 Eight major stroke clinical practiceguidelines (CPGs)2633 and two major UI CPGs17,18

were searched for recommendations regarding be-havioral approaches for the management of UI inindividuals with stroke and for references to RCTs.

Although we recognize that the AHCPR guidelineshave not been updated, we decided to includethem in the review because there are so few guide-lines making recommendations about inconti-nence. Finally, unpublished trial data weresearched for on national and international data-

bases including the Canadian Institute of HealthResearch Institute of Gender and Health (IGH)National Research Registry,34 Computer Retrievalof Information on Scientific Projects (CRISP) gen-erated in the United States,35 and the NationalResearch Register and the Department of HealthResearch Finding electronic Register (ReFeR) fromthe United Kingdom (UK).36 The flow chart of thereview process is presented in Figure 1. For thepurpose of this literature review, only peer-re-viewed articles were considered. Abstracts and

proceedings were excluded.

Data abstraction and analysis

Abstracts and references were reviewed to iden-tify RCTs and control studies evaluating behavioralinterventions for UI and including human subjectdata. RCTs were appraised for methodologicalquality using the PEDro Scale, developed by theCenter for Evidence-Based Physiotherapy in Aus-tralia.37 The PEDro score provides a nominativedescription of the aspects of a clinical trial that

affect its internal validity such as randomization;concealed allocation; baseline comparability;blinding of the subjects, assessors, and therapists;intention-to-treat analysis; and adequacy of fol-low-up. Two reviewers rated each RCT indepen-dently, and discrepancies in scoring were thendiscussed between the two reviewers. When agree-ment on certain points could not be reached, athird reviewer, a senior researcher with experiencein RCTs methodology, was consulted. Where anRCT already had a PEDro score in the PEDrodatabase, the existing score was used. PEDro scaleresults of individual studies were interpreted fol-lowing Foleys quality assessment20 where studiesscoring 9 to10 were considered methodologically

excellent, 6 to 8 were considered good, 4 to 5 wasfair, and below 4 waspoor.20 Cohort studies wereconsidered as an inferior form of evidence.

Data retrieved

In the first search, 35 citations were retrieved inMEDLINE and 62 in CINAHL. From these, twoRCTs were found.38,39 By reviewing the referencelists of retrieved articles, we identified two addi-tional RCTs40,41 and one additional cohort study.42

In the second search, we retrieved nine citations inMEDLINE and five citations in CINHAL. No newRCTs or cohort studies were found. In EMBASE,we retrieved 43 citations in the first search and oneadditional citation in the second. No new RCTs orcohort studies were found.

In ISI Web of Science database,25 no new RCTsciting major authors working in the area of UI inindividuals with stroke were found. In theCochrane database of systemic reviews,22 one sys-tematic review43 has been proposed but is not yet

published. In the PEDro database,23

two RCTs al-ready found in MEDLINE had PEDro scores.3840

In CENTRAL,24 no RCT related to individuals withstroke and behavioral treatments were found. Fi-nally, no unpublished trials were found in theCanadian Institute of Health Research Institute,IGH national research registry,34 in the AmericanCRISP,35 or in the UK National Research registerand the ReFeR.36 Table 1 summarizes the fourRCTs3841 and the only prospective cohort study42

found in the databases.Recommendations regarding behavioral man-


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agement of UI in individuals with stroke werefound in one major stroke CPG32 and two majorCPGs on UI.17,18 Recommendations were extractedand are presented in Table 2.

Results

Of the four RCTs, one cohort study and thethree CPGs where recommendations were found,five major subtopics emerged: timed voiding andprompted voiding, bladder retraining with urgesuppression, pelvic floor exercises alone, pelvicfloor exercises in combination with bladder re-training, and stroke rehabilitation approaches.

Timed voiding or prompted voiding

Timed voiding is a fixed time interval toiletingassistance program that has been promoted for the

management of people with UI who cannot par-ticipate in independent toileting.44 Prompted void-ing is a behavioral intervention that teaches peoplewith or without cognitive impairment to initiatetheir own toileting through requests for help incombination with positive reinforcement fromcare providers when voiding is successfully ac-

complished.45

Prompted voiding is different fromtimed voiding because the individual actively par-ticipates in initiation and maintenance of the void-ing process.Considering that timed and promptedvoiding have been shown to be effective for im-proving dryness in the frail elderly population,46 istimed voiding more effective than no intervention/placebo intervention or an alternative interventionin the management of UI in the adult stroke popu-lation?There is no RCT addressing these compari-sons. Is prompted voiding more effective than nointervention/placebo intervention or an alternative

Figure 1. Flow chart of the review process.


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Table1.Characteristicsoftherandomizedandnonrandomizedtrialsontheeffectsofbehavioraltreatm

entonUIinstrokepatients

Author

Popula

tion

Outcome

PEDro

year

Studydesign

characteristics

Intervention

measures

Ch

ange

score

Middaugh,

One-group

4male

strokepatientsliving

4weeksschedule-v

oiding

Continence:numberof

Allsubjectsachieved

Noscore

19894

2

pretest/

inthec

ommunitywitha

+25sessionsbiofeedback

leakage/weekat6and12

andmaintained

posttestdesign

clearhistoryofpersistentUI

assistedbladderretraining

months

continence

associatedwithstroke

(aged5

275)

Wilkander,

RCT

34strokepatients

Treatmentgroup:

-Urinarycontinence

Co

ntinence20/21inthe

5asperPEDrodatabasescore

19983

8

withUIfollowingstroke

compensatoryrehab

-KatzADLindex

treatmentgroupvs.

19females/15males

approach

-FIM-G7

3/1

3inthecontrolgroup

(meanage74)

vs.controlgroup:

-PGWBindex

remedialrehabilitation

-Mobilityscore

Greaterimprovementin

approach

all

outcomemeasuresin

the

compensatory

reh

abilitationapproach

gro

up

McDowell,

RCT

105homeboundolderadults

Biofeedbackassistedpelvic

%reductioninUI

75%reductioninUI

6asperPEDrodatabasescore

19994

0

withUI(aged6096)

floormuscletrainin

g

episode

episodeintreatment

28/105

withastroke

vssocializationvisit

gro

up

6.4

%reductioninUI

episodeincontrolgroup

Engberg,

RCT

16hom

eboundcognitively

8-weeklongpromp

ted

%reductiondaytimeUI

60%reductionindaytime

5

20024

1

impaire

dolderadultswithUI

voidingintervention

episode

UI

episodeintreatment

(aged6

0yearsandolder)

performedevery2hours

gro

up

37%reductionindaytime

UI

episodeincontrol

gro

up

Tibaeck,

RCT

26femalestrokepatientswith

12weeksofstandardized

SF-36

No

differenceinQOL

6

20033

9

UIcloselyassociatedwiththe

PFMexercisesvs.n

o

sco

resbetweenthe2

cerebro

vascularaccident

specifictreatmentfor

IIQ

gro

upsaftertreatment

(aged5

275)

incontinence

No

te:UI=urinaryincontinence;RCT=randomizedclinicaltrial;ADL=activitiesofdailyliving;PGW

B=psychologicalgeneralwell-beingindex;QOL=qualityoflife;PFM=pelvicfloormuscle;IIQ=Incon

tinenceImpact

Questionnaire.


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intervention in the management of UI in the adultstroke population? One RCT has evaluatedprompted voiding in cognitively impairedhomebound individuals, 20% of whom experi-enced a stroke.41 No results specific to the strokesubjects were reported, thus it was not possible todetermine the effect on this subgroup. Based onrecommendations from three CPGs,17,18,32 there isconsensus opinion that timed voiding or

prompted voiding should be implemented for uri-nary retention or incontinence in cooperative andmobile individuals with stroke.

Bladder retraining with urge suppression

Bladder retraining with urge suppression in-volves three components: educating patients aboutthe mechanisms underlying incontinence and con-

Table 2. Synthesis of the recommendations specific to behavioral approaches emitted by international clinicalpractice guidelines

Clinical Practice Guideline/

Group Recommendations specific to behavioral approaches for UI

Post-stroke Rehabilitation CPG #16/Agency for Management of incontinence should follow the AHCPR guidelines on UI in Adults

Health Care Policy and Research (AHCPR)26 CPG #2.

*Disclaimer not to use for clinical practice at this time.

UI in Adults CPG #2/ -The least invasive or dangerous procedures should be tried first. Behavioral

AHCPR17 management (pelvic muscle rehabilitation and/or behavioral therapies) meets

*Disclaimer not to use for clinical practice at this time. this criterion. (Research evidence from RCTs in adult population, expert opinions)

-For patients who have not been successfully treated, management plans must be

developed to maximize their well being. Techniques such as scheduled toileting

and prompted voiding may be useful in reducing the impact of the patients

incontinence. (Research evidence from RCTs in adult population, expert opinions)

Recommendations for stroke management/European No specific comments on behavioral techniques for UI

Stroke Initiative27

Best Practice Guidelines for Stroke Care/Heart and No specific comments on behavioral techniques for UI

Stroke Foundation of Ontario28

The Italian Guidelines for Stroke Prevention/ No specific comments on behavioral techniques for UI

The Stroke Prevention and Awareness Diffusion

(SPREAD) collaboration 29

National Clinical Guidelines for Stroke, 2nd ed./ No specific comments on behavioral techniques for UI

Royal College of Physicians, London, UK 30

Life after Stroke: New Zealand guideline for No specific comments on behavioral techniques for UI

management of stroke/Stroke Foundation of

New Zealand33

Management of Patient with Stroke/Scottish No specific comments on behavioral techniques for UI

Intercollegiate Guidelines Network 31

Veterans Affairs/Department of Defense (VADOD) Consider an individual bladder-training program that is developed and imple-

CPG for the management of stroke rehabilitation in mented for patients who are incontinent of urine (systematic review supporting

the primary care setting/VADOD32 management of urge UI in general population).

Recommend the use ofprompted voiding in stroke patients with UI (systematic

review evidence supporting short-term improvement of incontinence symptoms in

general population).

2nd International Consultation on Incontinence/ Behavioral modification (timed voiding) for the cooperative mobile patient

Abrams et al.18 (evidence from randomized and nonrandomized trials on nonstroke-specific

neurogenic UI).

xx


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tinence, a scheduled voiding regimen with gradu-ally progressive voiding intervals, and an urgencycontrol strategy using distraction and relaxationtechniques.47,48Bladder retraining requires patientsto be independent of caregiver support and moti-vated to participate actively in treatment.49 Con-sidering that there is strong evidence that bladderretraining with urge suppression is an effectivetreatment for adult women with urge, stress, andmixed symptom UI,48 is bladder training with urgesuppression more effective than no intervention/placebo intervention or an alternative interventionin the management of UI in the adult stroke popu-lation? There are no RCTs investigating this ques-tion. There is consensus opinion from one CPG32

that a bladder training program with urge suppres-sion should be implemented in individuals withsymptoms of urge incontinence post stroke.

Pelvic floor exercises

Pelvic floor exercises consist of a program ofrepeated voluntary pelvic floor muscle contrac-tions taught by a health care professional.48 Theseexercises aim to improve strength and/or timing ofthe pelvic floor contraction in the management of

stress incontinence and to inhibit detrusor con-traction in the management of urge incontinence.48

There is strong evidence that pelvic floor exercisesreduce UI in cognitively intact but frail elderlyindividuals.46 Are pelvic floor strengthening exer-cises more effective than no intervention/placebointervention or an alternative intervention in themanagement of UI in the adult stroke population?There is one RCT that investigated the use of pelvicfloor exercises in a stroke population.39 Twenty-sixmen and women were randomized to a 12-week

program of standardized pelvic floor strengthen-ing exercises or no treatment.39 After treatment, nodifference in continence-specific quality of life(QOL) (measured using the Incontinence ImpactQuestionnaire) or general QOL (based on SF-36scores) between the two groups was observed.39

No direct measurement of UI was used. Whilerating 6 on the PEDro scale, the very small samplesize of 24 participants (12 in each group) highlyincreased the likelihood of a type 2 error. In addi-tion, the choice of a QOL measure as a primary

outcome can be questioned as it may not havebeen sensitive enough to detect changes in UI QOLin a clientele where the disability associated withthe condition already impacts considerably onhealth-related QOL. Thus, this first RCT allows noconclusion regarding the effects of pelvic floorexercises in incontinent adults with stroke. Fur-thermore, there is no CPG that addresses the use ofpelvic floor exercises for the treatment of UI inindividuals with stroke. There is no evidence thatpelvic floor exercises should be recommended forindividuals with UI post stroke.

Bladder retraining with urge suppression in

combination with pelvic floor muscle exercises

Bladder retraining with urge suppression hasbeen used in combination with pelvic floor muscleexercises (inhibition of detrusor contractions) forUI in adults without neurological disease.18 It hasdemonstrated effectiveness in reducing inconti-nence episodes 3 months after randomization, ascompared to bladder retraining with urge suppres-sion alone.50 Is bladder retraining with urge sup-pression in combination with pelvic floor exercisesmore effective than no intervention/placebo inter-

vention or an alternative intervention in the man-agement of UI in the adult stroke population?There is one fair RCT40 and one nonrandomizedstudy42 that address these comparisons. InMiddaughs quasi-experimental study,42 using asingle-group pretest/posttest design, four malesubjects with chronic post stroke UI (average 1.6to 7.5 involuntary voids per week for at least 8months) participated in two to five training ses-sions withpelvic floor muscle exercises, urge sup-pression, and home pelvic floor exercises. All four

were evaluated for incontinence episodes prior totreatment, after treatment, and at 6-month follow-up. All achieved and maintained continence at the6-month follow-up evaluation.42 Although thisstudy provides evidence that there are individualswith persistent UI post stroke who can regain con-tinence following a program of pelvic floor muscleexercises, urge suppression, and home pelvic floorexercises, it is not possible to tell how typical thesefour subjects were or whether other individualswith UI post stroke would benefit similarly from


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this treatment. Such additional information re-quires more extensive RCTs.

McDowell et al.40 randomized 105 older adults(60 years and older) with UI to a biofeedback-assisted pelvic floor muscle training group (n = 53)or to a control group (n = 52) that received nospecific UI treatment.40 Twenty-eight participants(26%) had experienced a stroke (15 in the treat-ment group and 13 in the control group). Highlevels of comorbidity and functional impairmentsuch as heart failure, diabetes, and Parkinsonsdisease were found in the majority of participants.The treatment consisted of eight weekly sessions ofbiofeedback-assisted pelvic floor exercises andbladder retraining with urge suppression strategies

together with a daily home pelvic floor exerciseprogram. Participants in the treatment group withcomplete postcontrol data (n = 48) achieved amedian 75% reduction in incontinence episodes asopposed to 6.4% in the control group with com-plete postcontrol follow-up (n = 45) despite highlevels of comorbidity. Again, no results specific tothe participants with stroke were reported. Thereis limited evidence from one nonrandomizedstudy42 that bladder retraining with urge suppres-sion in combination with pelvic floor exercises

results in reduction of UI in male individuals withstroke. Further research is necessary before moredefinitive conclusions can be reached.

Rehabilitation approaches to neurological

impairment

There are two basic approaches to the rehabilita-tion of individuals with stroke. One approach, theremedial approach, involves use of neuro-develop-mental techniques that are directed at improving

the impairment and attempts to restore the strokepatients physical functioning as close to normal aspossible.51 The compensatory approach is not fo-cused on the return to normal physical functioningas much as it is focused on optimization of func-tion regardless of how it is accomplished.51 Cur-rently, clinicians use both methods, and there is noconsensus on which is more effective.51 However,the choice of rehabilitation approach may have animpact on the evolution of UI in stroke patients.The following question arises: In the adult stroke

population, does a specific rehabilitation approachhave an effect on UI?One RCT of fair quality wasfound: Wilkander et al.38 randomized 34 patientswith stroke to rehabilitation based on a compensa-tory rehabilitation approach or remedial approach.No specific UI treatment was given. A significantlygreater proportion of the compensatory group re-gained continence (20/21) as compared to the re-medial group (3/13). In addition, significantlygreater improvement in activities of daily living, inpsychological well-being, and in mobility was ob-served in the compensatory group compared tothe remedial group. These results can potentiallybe explained by the inherent philosophy of thecompensatory approach in which the patients in-

dependence in mobility and transfers is encour-aged more rapidly. There is moderate evidencefrom the results of one fair RCT38 that a function-ally oriented rehabilitation approach results in lessincontinence than the conventional approach inindividuals with stroke. A second RCT is needed toconstitute a strong level of evidence.

Discussion

Despite the high prevalence of persistent UI in

individuals with stroke, and a growing recognitionof the importance of using behavioral approachesas first-line treatment for managing UI, evidencespecific to the treatment of UI in individuals withstroke remains extremely limited. Evidence-basedpractice is the judicious use of current best evi-dence in making decisions about the care of indi-vidual patients.52 In the case of UI, this must beintegrated with clinical expertise and available re-search to provide rehabilitation professionals withthe information they need to improve the quality

of care of UI post stroke. At the current time,evidence-based recommendations for rehabilita-tion specialists to improve the quality of care of UIpost stroke include timed voiding for cooperativeand mobile stroke individuals unaware of theirbladder status and experiencing urinary retentionor UI; prompted voiding for cooperative and mo-bile individuals aware of their bladder status andexperiencing urinary retention or UI; and bladderretraining with urge suppression for those withurge symptoms who are independent of caregiver


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support and motivated to participate actively intreatment. Although there is moderate evidencethat a functionally oriented rehabilitation ap-proach results in reduced incontinence, the ab-sence of level 1 evidence suggests that therapistsconsider combining the two approaches (function-ally oriented and conventional rehabilitation ap-proach) in treating individuals with stroke,thereby encouraging independence in mobilityand transfers. Finally, specific to male individualspost stroke who have urge symptoms and who areindependent of caregiver support and motivated toparticipate actively in treatment, bladder retrain-ing with urge suppression together with pelvicfloor muscle exercises is recommended.

Conclusion

The effectiveness of various behavioral ap-proaches in the management of UI in individuals

post stroke is not well studied. Preliminary re-search suggests that important improvements inUI can be achieved using a number of behavioral

strategies for UI that are employed for nonstrokepatients. Further research is urgently needed, be-cause UI is a strong predictor of functional recov-ery and discharge destination.

Acknowledgments

C. Dumoulin was supported by a postdoctoralfellowship from the Fond de la Recherche en Santdu Qubec (FRSQ) and from infrastructure sup-port from the Canadian Stroke Network and CRIR.

REFERENCES

1. Van Kuijk AA, Van der Linde H, Van Limbeek J.Urinary incontinence in stroke patients after admis-

sion to a post acute inpatient rehabilitation pro-gram. Arch Phys Med Rehabil. 2001;82(10):14071411.

2. Kolominsky-Rabas PL, Hiltz M, Neundoerfer B,Heuschmann PU. Impact of urinary incontinenceafter stroke: results from a prospective population-based stroke register. Neurourol Urodynamics.2003;22:322327.

3. Coleman Gross J. Urinary incontinence after stroke:evaluation and behavioral treatment. Top GeriatrRehabil. 2003;19(1):6083.

4. Brocklehurst JC, Andrews K, Richards B, Laycock PJ.Incidence and correlates of incontinence in strokepatients.J Am Geriatr Soc. 1985;33:540542.

5. Borrie MJ, Campbell AJ, Carodoc-Davies TH, Spears

GF. Urinary incontinence after stroke: a prospectivestudy. Age Ageing. 1986;15:177181.

6. Patel M, Coshall C, Rudd AG, Wolfe CD. Naturalhistory and effects on 2-years outcomes of urinaryincontinence after stroke. Stroke. 2001;32:122127.

7. Taub NA, Wolfe CDA, Richardson E, Burney PGJ.Predicting the disability of first-time stroke sufferersat 1 year: 12 month follow-up of a populationbased cohort in the southeast England. Stroke.1994;25:352357.

8. Brittain K. Stroke and continence care. Nurs Times.2001;97:3056.

9. Ween JE, Alexander MP, DEsposito M, Roberts S.Incontinence after stroke in a rehabilitation setting:

outcome associations and predictive factors. Neurol-ogy. 1996;47:659663.

10. Gallagher M. Urogenital distress and the psychoso-cial impact of urinary incontinence in elderlywomen. Rehabil Nurs. 1998;23(4):192197.

11. Mayo NE, Korner-Bitensky N, Becker R, Georges P.Predicting falls among patients in a rehabilitationhospital. Am J Phys Med Rehabil. 1989;68(3):139146.

12. Eldar R, Ring H, Tshuwa M, Dynia A, Ronen R.Quality of care for urinary incontinence in a rehabili-tation setting for patients with stroke. Simultaneousmonitoring of process and outcome. Int J QualityHealth Care. 2001;13(1):5761.

13. Sakakibara R, Hattori T, Yasuda K, Yamanishi T.Micturitional disturbance after acute hemisphericstroke: analysis of the lesion site by CT and MRI. J

Neurol Sci. 1996;137:4756.14. Gelber DA, Good DC, Laven LJ, Verhulst SJ. Causes

of urinary incontinence after acute hemisphericstroke. Stroke. 1993;24:378382.

15. Olsen-Vetland P. Urinary continence after acerbrovascular accident. Nurs Stand. 2003;17(39):3741.

16. Agency for Health Care Policy and Research(AHCPR). Urinary Incontinence Guideline Panel. Uri-nary Incontinence in Adults. Rockville, MD: US De-partment of Health and Human Services; 1992.

17. Agency for Health Care Policy and Research(AHCPR). Urinary Incontinence Guideline Panel. Uri-nary Incontinence in Adults: Acute and Chronic Man-


10/11


agement. Clinical Practice Guideline. Rockville, MD:US Department of Health and Human Services;1996.

18. Abrams P, Cardozo L, Khoury S, eds. Incontinence.Second International Consultation on Incontinence,2nd ed. UK: Health Publication Ltd.; 2002.

19. The evidence-based medicine working group. In:Guyatt G, Rennie D, eds. Users Guides to the MedicalLiterature: A Manual for Evidence-Based Clinical Prac-tice. Chicago, IL: AMA Press; 2002:736.

20. Foley NC, Teasell RW, Bhogal SK, Speechley MR.Stroke rehabilitation evidence-based review: meth-odology. Top Stroke Rehabil. 2003;10(1):17.

21. Sackett DL, Richardson WS, Rosenberg W, HaynesRB. Evidence-Based Medicine: How to Practice andTeach EBM. New York: Churchill-Livingstone; 1997.

22. Cochrane database of systematic review in theCochrane Collaboration Cochrane Library. 2004.

Available at: http://www.cochranelibrary.com/col-

laboration/. Accessed July 2004.23. Physiotherapy evidence database (PEDro). 2004.Available at: http://www.pedro.fhs.usyd.edu.au.Accessed July 2004.

24. Cochrane central register of controlled trials (CEN-TRAL) in the Cochrane Collaboration Cochrane Li-brary. 2004. Available at: http://www.cochranelibrary.com/collaboration/. Accessed July2004.

25. ISI Web of Knowledge. ISI Web of Science. 2004.Avai labl e at : ht tp :/ /i si 6. is iknowl edge .com/portal.cgi. Accessed July 2004.

26. Agency for Health Care Policy and Research, Post-stroke Rehabilitation Guideline Panel. Post-strokeClinical Practice Guideline No. 16. Rockville, MD: US

Department of Health and Human Services; 1995.27. The European Stroke Initiative. Recommendations

for Stroke Management-update 2003. Cerebrovas-cular dis. 2003; 16:311-337. Available at: http://www.eusi-stroke.org/. Accessed July 2004.

28. Heart and Stroke foundation of Ontario.Best Prac-tice Guidelines for Stroke Care. 2003. Available at:http://www.hsfpe.org/. Accessed July 2004.

29. Stroke Prevention and Educational Awareness Diffu-sion (SPREAD) collaboration. The Italian guidelines

for stroke prevention. Neuro Sci. 2000;21:512.30. Royal College of Physicians (RCP), London. National

Clinical Guidelines for Stroke. 2004. Available at:http://www.rcplondon.ac.uk/pubs/. Accessed Sep-tember 2004.

31. Scottish Intercollegiate Guidelines Network (SIGN).Management of patients with stroke; rehabilitation,prevention and management of complications anddischarge planning: A national clinical guideline.2002. Edinburgh, Scotland. Available at:www.sign.ac.uk. Accessed July 2004.

32. Veterans Affairs and Department of Defence(VADOD). Management of stroke rehabilitation inprimary care setting. 2003. Available at: http://www1.va.gov/stroke-queri/clinical_guidelines.htm.

Accessed July 2004.33. Stroke Foundation of New Zealand. Life after stroke;

New Zealand guideline for management of stroke.2003. Available at: http://www.nzgg.org.nz/

index.cfm?screensize=1024&ScreenResSet=yes. Ac-cessed September 2004.

34. Canadian Institute of Health Research Institute ofGender and Health (IGH) National Research Regis-try. Available at: http://www.igh.ualberta.ca. Ac-cessed July 2004.

35. Computer Retrieval of Information on ScientificProjects (CRISP) generated in the US. Available at:http://www.crisp.cit.nih.gov. Accessed July 2004.

36. National Research Register and the Department ofHealth Research Finding electronic Register (ReFeR),UK. Available at: http://www.dh.gov.uk. AccessedJuly 2004.

37. Moseley AM, Herbert RD, Sherrington C, Maher CG.Evidence for physiotherapy practice: a survey of thePhysiotherapy Evidence Database (PEDro). Aust JPhysiother. 2002;48(1):4349.

38. Wilkander B, Ekelund P, Milsom I. An evaluation ofmultidisciplinary intervention governed by func-

tional independence measure (FIMSM

) in incontinentstroke patients. Scand J Rehabil Med. 1998;30(1):1521.

39. Tibaek S, Jensen R, Lindskov G, Jensen M. Can qual-ity of life be improved by pelvic floor muscle trainingin women with urinary incontinence after ischemicstroke? A randomized, controlled and blindedstudy. Int Urogynecol J Pelvic Floor Dysfunct.2004;15(2):117123.

40. McDowell BJ, Enberg S, Sereika S, et al. Effectivenessof behavioral therapy to treat incontinence inhomebound older adults.J Am Geriatr Soc. 1999;47:309318.

41. Engberg S, Sereika SM, MCDowell BJ, Weber E, BrodI. Effectiveness of prompted voiding in treating uri-

nary incontinence in cognitively impairedhomebound older adults. J Wound Ostomy Conti-nence Nurs. 2002;29(5):252265.

42. Middaugh SJ, Whitehead WE, Burgio KL, Engel BT.Biofeedback in treatment of urinary incontinence instroke patients. Biofeedback Self-Regul. 1989;14(1):319.

43. Thomas LH, Barrett J, Cross S, French B, Leathley M,Legg L, Sutton C, Watkins C. Prevention and treat-ment of urinary incontinence after stroke in adults(Protocol). In: The Cochrane Library, Issue 2.Chichester, UK: John Wiley & Sons, Ltd.; 2004.

44. Ostaszkiewicz J, Johnston L, Roe B. Timed voidingfor the management of urinary incontinence inadults. (Cochrane Review). In: The Cochrane Library,Issue 2. Chichester, UK: John Wiley & Sons, Ltd.;2004.

45. Eustice S, Roe B, Paterson J. Prompted voiding forthe management of urinary incontinence in adults.(Cochrane Review). In: The Cochrane Library, Issue 4.Chichester, UK: John Wiley & Sons, Ltd.; 2004.

46. Fonda D, Benvenuti F, Cottenden A, Dubeau C,Kirshner-Hermanns R, Miller K, Palmer M, Resnick N.Urinary incontinence and bladder dysfunction inolder persons. In: Abrams P, Cardozo L, Khoury S,eds. Incontinence. Second International Consultationon Incontinence, 2nd ed. UK: Health Publication Ltd.;2002.

47. Burgio KL, Locher JL, Goode PS, Hardin M,


11/11


McDowell BJ, Dombrowski M, Candib D. Behavioralvs drug treatment for urge urinary incontinence inolder women: a randomized control trial.JAMA.1998;280(23):19952000.

48. Wilson PD, Bo K, Hay-Smith J, Nygaard I, Staskin D,Wyman J. Conservative treatment in women. In:Abrams P, Cardozo L, Khoury S, eds. Incontinence.Second International Consultation on Incontinence,2nd ed. UK: Health Publication Ltd., 2002.

49. Tannenbaum C, Perrin L, Dubeau CE, Kuchel GA.Diagnosis and management of urinary incontinencein the older patient. Arch Phys Med Rehabil.2001;82:134138.

50. Wyman JF, Fantl JA, McClish DK, Bump RC. Com-parative efficacy of behavioral interventions in themanagement of female urinary incontinence. Am JObstet Gynecol. 1998;179(4):9991007.

51. Teasell RW, Jutai JW, Bhogal SK, Foley NC. Researchgaps in stroke rehabilitation. Top Stroke Rehabil.2003;10(1):5970.

52. Bury T, Mead J. Evidence-based Health Care: A Guidefor Therapists. Boston: Butterworth-Heinemann;1998.

APPENDIX A

Summary of the Definition of Evidences20

Strong The findings were supported by the results of two or more RCTs of at least fair quality.

Moderate The findings were supported by a single RCT of at least fair quality.

Limited The findings were supported by at least one nonexperimental study (non-RCT, cohort studies, etc.).

Consensus In the absence of evidence, agreement was reached by a group of experts on the appropriate treatment course.

Conflicting There was disagreement between the findings of at least two RCTs. Where there were more than four RCTs andthe results of only one was conflicting, the conclusion was based on the results of the majority of the studies,unless the study with conflicting results was of higher quality.

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