Urinary Incontinence After Stroke
Identification, Assessment, and Intervention by Rehabilitation
Professionals in Canada
Chantale Dumoulin, PhD; Nicol Korner-Bitensky, PhD; Cara Tannenbaum, MD, MSc
Downloaded from http://stroke.ahajournals.org/ by guest on June 15, 2017
Background and Purpose—Urinary incontinence (UI) is a common and distressing problem after stroke. Although there
is evidence of new, effective UI poststroke rehabilitation intervention, it is unknown whether occupational therapists
(OTs)’ and physical therapists (PTs)’ actual practices reflect best practices. We sought to determine the extent to which
OTs and PTs identify, assess, and treat UI after stroke and to identify personal and organizational predictors of UI
problem identification, best-practice assessment, and intervention.
Methods—Six hundred sixty-three OTs (93% participation rate) and 656 PTs (87% participation rate) working in stroke
rehabilitation in Canada were randomly selected and interviewed with a telephone-administered questionnaire. Each
responded to a series of open-ended questions related to a generated case (vignette) of a typical client with stroke who
was experiencing UI.
Results—Only 39% of OTs and 41% of PTs identified UI after stroke as a problem. Fewer than 20% of OTs and 15% of
PTs used best-practice assessments, and only 2% of OTs and 3% of PTs used best-practice interventions. Working in
Ontario, having allocated learning time, and doing university teaching were among the variables explaining between 6%
and 9% of the variability in UI identification and assessment.
Conclusions—Canadian OTs and PTs do not routinely identify poststroke UI as a problem, and best-practice assessments
and interventions are underused. (Stroke. 2007;38:2745-2751.)
Key Words: evidence-based practice 䡲 rehabilitation 䡲 stroke 䡲 urinary incontinence
U
mendations10 suggest a protocol including a urinary diary,
symptoms and quality-of-life, UI-specific questionnaires, a
physical examination including pelvic floor evaluation, an
evaluation of toilet transfer, and the need for adaptive
equipment. There are also stroke-specific and generic functional measures that include items related to toileting.11–15
Management of UI after stroke includes the use of supportive devices and behavioral, pharmacological, and surgical
interventions.10 Behavioral interventions include timed voiding, prompted voiding, bladder retraining with urge suppression, pelvic floor muscle training, and compensatory rehabilitation approaches.16,17 Recommendations from the Agency
for Health Care Policy and Research Guidelines6 and the
International Consultation on Incontinence10 indicate that the
least invasive UI intervention, behavioral management,
should come first.6,10
For UUI, there is evidence, albeit limited, that bladder
retraining with urge suppression in combination with pelvic
floor muscle exercises results in reduction of UI after
stroke.16 For FUI, 1 fair-quality, randomized, clinical trial has
shown a functional rehabilitation approach to be more effec-
rinary incontinence (UI) is a major problem after stroke,
with a prevalence ranging from 37% to 79% in the days
and weeks after the infarct.1,2 One year after stroke, approximately one third of these individuals remain incontinent.2,3
UI is a strong predictor of functional recovery,4 discharge
destination,4 and resumption of social participation.5
There are 3 poststroke UI disorders that can be affected by
occupational therapy and/or physical therapy intervention:
urge (UUI), functional (FUI), and stress (SUI).6,7 UUI is the
complaint of involuntary leakage accompanied by or preceded by urgency7 that can result from a stroke-related infarct
or cerebral edema affecting central micturition pathways.8
FUI is the inability to maintain continence because of
functional impairments, such as hemiparesis or impaired
mobility, and environmental barriers, such as reduced toilet
accessibility.6 SUI is the complaint of involuntary leakage on
effort, sneezing, or coughing.7 SUI often precedes stroke
onset but is typically exacerbated after stroke by repeated
coughing associated with dysphagia and aspiration.9
Although no stroke-specific UI rehabilitation assessments
exist, the International Consultation on Incontinence recom-
Received February 23, 2007; final revision received April 17, 2007; accepted April 18, 2007.
From the Faculty of Medicine, School of Physical and Occupational Therapy, McGill University, and the Centre de recherche interdisciplinaire en
réadaptation du Montréal métropolitain (C.D., N.-K.B.); and the Faculty of Medicine, University of Montreal, and the Centre de recherche de l’Institut
Universitaire de Gériatrie De Montréal (C.T.), Montreal, Canada.
Correspondence to Chantale Dumoulin, PhD, School of Physical and Occupational Therapy, McGill University, 3630 Promenades Sir-William-Osler,
Montreal, Quebec, H3G 1Y5, Canada. E-mail [email protected]
© 2007 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.107.486035
2745
2746
Stroke
October 2007
Downloaded from http://stroke.ahajournals.org/ by guest on June 15, 2017
tive than a remedial approach.18 For SUI, there is evidence
from 1 fair-quality, randomized, clinical trial that pelvic floor
muscle exercise has a significant effect in females after
stroke.19 Thus, although management has fallen primarily on
nurses and physicians, there is emerging evidence supporting
the need for an interdisciplinary approach incorporating
occupational therapists (OTs) and physical therapists
(PTs).16,20 OTs have the expertise to play a strong role in
reducing UI severity that is related to environment factors and
specific needs for aids and adaptations.20 PTs can intervene
with mobility and transfers that exacerbate UI-related problems and have expertise in pelvic floor muscle training.16
A review of the literature identified no studies regarding
UI-related rehabilitation practices after stroke. This study therefore reports stroke-related UI rehabilitation practices of Canadian OTs and PTs, with the specific goals of identifying the
detection of UI after stroke as a problem in those who are
affected; the use of best-practice assessments and interventions
related to UI management; and the relation between personal
and organizational variables that have been shown to be associated with practice behaviors21 and variations in problem identification, assessment, and intervention practices.
Subjects and Methods
Research Design
A cross-sectional, Canada-wide telephone survey was undertaken to
investigate UI practice patterns of OTs and PTs working with
patients across the continuum of stroke care. Prompted by a case
vignette depicting a typical patient with stroke being treated in either
acute care, inpatient rehabilitation, or community outpatient services,
clinicians were asked to identify problems, assessments, and interventions that they would use. Ethics approval was provided by the
institutional review board, Faculty of Medicine, McGill University,
Montreal, Canada.
Sample Size Considerations
Sample sizes were based on the estimate that 20% of therapists
would use interventions with high evidence of effectiveness. With a
2-sided CI of 95% and a desired precision of 6%, ⬇200 therapists
per discipline per UI type were required to allow stable prevalence
estimates.22
Study Population
The goal was to accrue a representative random sample of OTs and
PTs working across the continuum of stroke care in Canada. The
Canadian professional associations and provincial licensing bodies
provided lists of clinicians working in adult neurology. In smaller
provinces, the orders provided hospital names and community
clinics. Disproportional sampling was used to ensure sufficient
numbers by province and setting.
Clinicians were eligible if they were registered with the licensing
body; had worked in stroke rehabilitation ⱖ3 months during the
year; had worked in the previous 6 months; had treated ⱖ2 adult
clients with a primary diagnosis of stroke per month; spoke English
or French; and provided informed consent.
Development of the Clinical Vignette and
Interview Questionnaire
Previous work has demonstrated that case studies are a valid form of
treatment ascertainment.23 Using focus-group methodology, 3 vignettes representing the different environments in which clinicians
practice were developed by stroke clinicians and researchers, taking
into consideration the different phases of stroke rehabilitation and
different types of UI (SUI, UUI, and FUI). Vignettes were created in
either English or French and then translated according to standard
procedures, after which they were pilot-tested on 5 clinicians.24
In the acute-care vignette, the sentence, “The spouse expresses
concern that P. leaks a small amount of urine when coughing and
sneezing” was used to represent SUI. In the rehabilitation vignette,
UUI was represented by “The nursing staff noted that J. is often in
a great hurry to get to the bathroom and doesn’t always make it on
time.” In the community vignette, the FUI-related sentences included
“C. ambulates at a slow pace with assistance of a quad cane” “Last
week, C. fell while in the bathroom”; and “Since the stroke, C. does
not always make it to the bathroom on time.”
The interview questionnaire was designed according to Dillman’s
guidelines.25 We have used a similar version successfully in a
previous study of low back pain.26 Because it was adapted slightly
for this study, the questionnaire was again reviewed for face validity
and pretested on 6 clinicians. Questionnaire components included
personal and organizational characteristics; the clinical vignette
pertinent to the clinician’s work setting; and questions related to the
clinician’s actual practices, including the problems identified in the
patient depicted in the vignette, as well as the assessments and
interventions that the clinician would use.
Tracing, Recruiting, and Interviewing Participants
Rigorous tracing procedures were implemented. Once contacted, the
clinician was screened for eligibility. The project was described, and
those who were eligible and consented were scheduled for a
telephone interview. The vignette matching the clinician’s work
environment, an explanatory letter ensuring confidentiality, and a
request not to divulge the contents of the study were forwarded to
participants 24 to 48 hours before the interview. Ten interviewers
were extensively trained and provided with written guidelines to
follow when performing the interviews and responding to clinician
queries.25 Responses to the interview were numerically coded and
entered in a management system.
Data Analysis
Descriptive statistics were used to indicate the prevalence of problem
identification, assessment, and intervention use, by discipline and UI
type. Problem identification was operationally defined in 2 ways:
“UI problem identifier,” to denote a clinician who used a UI-related
term, and “specific UI type problem identifier,” to denote a clinician
who identified the specific UI type (Table 1). Assessment use was
also operationally defined in 2 ways: “UI assessment user,” to denote
a clinician who indicated any UI assessment, and “best-practice UI
assessment user,” to denote a clinician who identified best-practice
assessment(s). The term “UI intervention user” denoted a clinician
who used any form of UI intervention, whereas “best-practice UI
intervention user” denoted a clinician who identified best-practice
intervention(s) for the specific UI described. Finally, a clinician who
identified all 3 aspects of UI management, the problem, best-practice
assessment, and best practice-intervention, was termed a “bestpractice user” with prevalence calculated by discipline.
Univariate analyses examined the association between 23 potential
explanatory variables and being a UI problem identifier and bestpractice UI assessment user, for OTs and PTs independently.
Personal predictors were sex, age, degree, year of graduation, years
of experience with stroke patients, province of practice, work
schedule (part versus full time), hours treating daily, number of
stroke patients seen daily, vignette type (SUI, UUI, or FUI), specialty
certification, and university teaching. Organizational predictors were
work setting (inpatient, outpatient, or community), work location
(urban, suburban, or rural), and yes/no to the following items:
provide student placement, teaching institution, research in setting,
nurse in practice, social worker in practice, interdisciplinary team,
allocated learning time, funds for learning, and easy access to new
information. Given the multiple correlations, the probability value
was set at 0.01 with a Bonferroni correction.
Next, 4 logistic-regression models, with stepwise backward elimination and iterative modeling of variables, were used to determine
which combination of variables predicted being an OT or PT “UI
problem identifier” and “best-practice UI assessment user.” The
Dumoulin et al
Rehabilitation for UI After Stroke in Canada
2747
TABLE 1. OT and PT Responses Used in Coding Problem Identification,
Assessments, and Interventions
Variable Name
Operational Definition
UI problem identifier
Bladder problem, continence problem, urinary incontinence,
SUI, UUI, FUI, and toileting.
Type-specific UI problem identifier
SUI for the acute-care vignette, UUI for the rehabilitation
vignette.
FUI and toileting for the community vignette.
UI assessment user
Bladder assessment, incontinence assessment, referral
to nurse or urologist, urinary diary, symptoms and
quality-of-life UI-specific questionnaires, physical
examination including mobility evaluation, pelvic floor
evaluation, toilet transfer and toileting, adaptive bathroom
equipment needs, generic functional independence
measures with UI content.
Best-practice UI assessment user
Urinary diary.
Symptoms and quality-of-life UI-specific questionnaires.
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Pelvic floor evaluation.
Toilet transfer and toileting.
Bathroom-adaptive equipment needs.
Generic functional independence measures with UI content.
UI intervention user
Bladder treatment, incontinence treatment, continence
treatment, pelvic floor exercises, bladder retraining with urge
suppression in combination with pelvic floor muscle
exercises, toileting, and toilet aids.
Best-practice UI intervention user
Pelvic floor exercises for the SUI vignette.
Bladder retraining with urge suppression in combination
with pelvic floor muscle exercises, or pelvic floor muscle
exercises alone, for the UUI vignette.
Toileting and toilet aids for the FUI vignette.
prevalence of the outcome “UI intervention user” was insufficient to
allow logistic-regression analyses. Independent variables with a
univariate significance ⱕ0.10 with the outcome were included.
Results for significant predictors are reported using odds ratios and
95% CIs.
Results
Respondents
The survey was completed in 2004 to 2005, with 1072 OTs
contacted, 290 ineligible, 71 untraceable, and 48 refusing:
thus, 663 of 711 (93%) of eligible OTs participated. For PTs,
1024 were contacted, 171 were ineligible, 99 were untraceable, and 98 refused: 656 of 754 (87%) of eligible PTs
participated. Table 2 summarizes the sociodemographic characteristics of participants per discipline and setting.
Clinician Practices
Table 3 presents the prevalence of UI identification, bestpractice assessment, and intervention. A similar proportion of
OTs and PTs identified a UI problem, but type-specific UI
identification was rare. UI assessment was uncommon, as
was intervention. Fewer than 1% of clinicians were classified
as “best-practice users.”
Variables Associated With Identification of UI and
Use of Best-Practice Assessments
For OTs, a univariate analysis of factors associated with
being a “UI problem identifier,” showed a significant effect
of vignette type: 53.5% of those who answered an SUI
acute-care vignette were identifiers versus 29.6% of those
responding to the UUI rehabilitation and 37.0% of those
responding to the FUI community vignette (␹2⫽26.02,
P⫽0.001). For PTs, vignette type was again associated:
50.9% of those answering an SUI acute-care vignette were
identifiers versus 36.8% answering the UUI rehabilitation and
34.6% answering the FUI community vignette (␹2⫽13.82,
P⬍0.001). PT identifiers compared with nonidentifiers were
also more likely to have a social worker in their setting,
82.3% versus 71.4% (␹2⫽10.24, P⫽0.001).
Univariate analyses of factors associated with being a
best-practice UI assessment user showed, for OTs, a significant effect of hours treating daily: 32.8% of those treating
stroke patients for ⬎2 hours daily were users versus 14.2% of
those who treated ⬍1 hour and 13.8% of those who treated 1
to 2 hours daily (␹2⫽30.63, P⬍0.001), and number of stroke
patients seen daily: only 14.4% of those seeing ⬍2 stroke
patients daily were users versus 18.9% of those seeing 2 to 5
patients and 36.5% of those seeing ⱖ6 patients daily
2748
Stroke
TABLE 2.
October 2007
Characteristics of Respondent by Discipline, UI Type, and Clinical Setting
OTs (N⫽663)*
SUI Acute
Care
(n⫽183)
UUI
Rehabilitation
(n⫽253)
FUI
Community
(n⫽227)
SUI Acute
Care
(n⫽202)
UUI
Rehabilitation
(n⫽223)
FUI
Community
(n⫽231)
35.47 (8.13)
36.67 (9.19)
38.12 (9.36)
38.78 (9.40)
39.84 (9.63)
42.52 (9.84)
168 (91.8)
231 (91.3)
211 (93.0)
181 (89.6)
197 (88.3)
202 (87.4)
Characteristic
Mean age, y (SD)
PTs (N⫽656)*
Women, n (%)
Training, n (%)
Diploma, entry level
Bachelor’s degree
Master’s and doctoral degrees
3 (1.6)
11 (4.3)
20 (8.8)
21 (10.6)
28 (12.6)
40 (17.4)
168 (91.8)
231 (91.3)
202 (89.0)
176 (88.4)
185 (83.0)
180 (78.3)
12 (6.6)
11 (4.3)
5 (2.2)
2 (1.0)
10 (4.4)
10 (4.3)
143 (78.1)
195 (77.1)
141 (62.1)
157 (78.1)
176 (78.9)
159 (68.8)
⬍3
53 (29.3)
76 (30.2)
53 (23.3)
44 (22.0)
54 (24.3)
35 (26.7)
4–10
69 (38.1)
80 (31.7)
69 (30.4)
61 (30.5)
64 (28.8)
65 (28.1)
⬎10
59 (32.6)
96 (38.1)
105 (46.3)
95 (47.5)
104 (46.6)
131 (56.7)
⬍2
75 (41.2)
52 (20.6)
144 (63.4)
83 (41.1)
47 (21.1)
139 (60.7)
2–5
90 (49.5)
144 (56.9)
72 (31.7)
82 (40.6)
122 (54.7)
73 (31.9)
ⱖ6
17 (9.3)
57 (22.5)
11 (4.8)
37 (18.3)
54 (24.2)
17 (7.4)
⬍1
79 (43.6)
68 (26.9)
78 (34.4)
96 (47.5)
52 (23.4)
85 (37.0)
1–2
73 (40.3)
69 (27.3)
105 (46.3)
60 (29.7)
73 (32.9)
93 (40.4)
⬎2
29 (16.0)
116 (45.8)
44 (19.4)
46 (22.8)
97 (43.7)
52 (22.6)
127 (69.8)
166 (65.6)
131 (57.7)
149 (73.8)
162 (73.0)
106 (45.9)
57 (31.1)
91 (36.0)
72 (31.7)
72 (35.6)
93 (41.7)
88 (38.3)
Full-time work, n (%)
Years of experience, n (%)
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Stroke patients seen daily, n (%)
Hours treating daily, n (%)
Teaching institution, n yes (%)
Allocated learning time, n yes (%)
*Ns vary slightly due to missing data.
(␹2⫽20.28, P⬍0.001). For PTs, vignette type and hours
treating daily were associated with being a user: of those
answering a UUI rehabilitation vignette, 22.9% were users
versus 8.4% of those answering an SUI acute-care vignette
and 12.1% of those answering an FUI community vignette
(␹2⫽19.53, P⬍0.001), and 21.5% of those treating ⬎2 hours
daily were users versus 8.6% of those treating ⬍1 hour and
15.0% of those treating 1 to 2 hours daily (␹2⫽14.26,
P⫽0.001).
In building the UI problem identifier logistic-regression
models with variables that were univariately significant at
P⬍0.10, 5 were included for OTs: year of graduation,
vignette type, research in setting, student placement, and
funds for learning: 8 were included for PTs: age, vignette
type, years of experience, specialty certification, work
setting, social worker in the practice, interdisciplinary
team, and allocated learning time. For the UI best-practice
assessment user logistic-regression model, 11 variables
were included for OTs: year of graduation, hours treating
daily, sex, province of practice, vignette type, work schedule, number of stroke patients seen daily, work setting,
student placement, nurse in practice, and research in
setting; 11 were included for PTs: hours treating daily,
province of practice, vignette type, years of experience,
number of stroke patients seen daily, university teaching,
work setting, work location, nurse in practice, research in
setting, and easy access to new information.
Multivariate analysis (Table 4) showed that vignette type
(SUI acute-care versus FUI community) and presence of
student placement explained 6.5% of the variability in UI
problem identification for OTs. For PTs, 3 factors, vignette
type (SUI acute-care versus FUI community), allocated
learning time, and the presence of a social worker in the
practice, were significantly associated with UI problem identification. The final model explained only 5.8% of the
outcome.
For OTs, the model that best explained being a bestpractice UI assessment user (Table 3) included working in
Ontario versus the other provinces (27.3% of Ontario OTs
were users versus 15.6% in other provinces), working full
time versus part time, and hours treating daily (⬎2 hours
versus ⬍1 hour), which together explained 9.0% of the
variability in the outcome. For PTs, hours treating daily (⬎2
hours versus ⬍1 hour), vignette type (UUI rehabilitation
versus FUI community), and undertaking university teaching
explained 8.4% of the variability.
Discussion
UI Detection, Assessment, and Intervention
Canadian rehabilitation professionals do not routinely identify UI after stroke. Furthermore, best-practice assessments
and interventions are seldom used. It could be argued that this
low prevalence of UI management is unimportant, given that
nurses and doctors have traditionally been responsible for UI
Dumoulin et al
Rehabilitation for UI After Stroke in Canada
2749
TABLE 3. Prevalence of Identification, Assessment, and Intervention by Discipline, UI Type, and
Clinical Setting
OTs (N⫽663)*
PTs (N⫽656)*
SUI Acute
Care
(n⫽183)
UUI
Rehabilitation
(n⫽253)
FUI
Community
(n⫽227)
SUI Acute
Care
(n⫽202)
UUI
Rehabilitation
(n⫽223)
FUI
Community
(n⫽231)
98 (53.55)
75 (29.64)
84 (37.00)
103 (51.00)
82 (36.77)
80 (34.63)
5 (2.73)
12 (4.74)
34 (14.98)
5 (2.48)
13 (5.83)
26 (11.26)
32 (17.49)
61 (24.11)
38 (16.74)
17 (8.42)
51 (22.87)
30 (12.99)
Variable name
UI problem identifier, n (%)
Specific UI type
Problem identifier, n (%)
UI assessment user, n (%)
Best-practice UI
Assessment user, n (%)
32 (17.49)
61 (24.11)
35 (15.42)
17 (8.42)
51 (22.87)
28 (12.12)
UI intervention user, n (%)
17 (9.29)
30 (11.86)
23 (10.13)
15 (7.43)
16 (7.17)
7 (3.03)
Best practice
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Intervention user, n (%)
0 (0)
0 (0)
16 (7.05)
8 (3.96)
10 (4.48)
4 (1.73)
Best-practice user, n (%)
0 (0)
0 (0)
4 (0.60)
1 (0.15)
1 (0.15)
1 (0.15)
*Ns vary slightly due to missing data.
management. Emerging scientific evidence16,17,18,19 that rehabilitation professionals play a key role in reducing the effect
of poststroke UI and published UI recommendations indicating the need for multidisciplinary attention to continence
care6,10 suggest otherwise.
Overall, the 23 potential explanatory variables were only
minimally successful in identifying UI problem identifiers
and best-practice assessment users for both OTs and PTs.
Problem identification and best-practice assessment were
related to vignette type. For example, PTs and OTs answering
an SUI acute-care vignette were more likely to be UI problem
identifiers than those answering the FUI community vignette.
It is possible that rehabilitation professionals are more attuned to identifying SUI, which is worsened by effort and
exertion required to participate in rehabilitation interventions and concomitantly affects concentration during treatment. Alternatively, it may be that those working in an
acute-care setting are more vigilant about UI, considering that
TABLE 4. Multivariate Analyses of Personal and Organizational Factors According to Problem
Identification and Assessment by Discipline
OTs
Models
OR*
95% CI
UI problem identifier
PTs
Nagelkerke R 2
OR*
95% CI
0.065
Nagelkerke R 2
0.058
Vignette type: FUI community vs
SUI acute care
1.94
1.29–2.93
1.80
1.19–2.71
UUI rehabilitation
0.68
0.46–1.01
0.98
0.65–1.49
Student placement⫽yes
2.22
1.07–4.64
N/A
Allocated learning time⫽yes
N/A
1.42
1.01–2.00
Social worker⫽yes
N/A
1.88
1.24–2.87
Best-practice UI assessment user
Province of practice⫽Ontario vs others
0.090
1.73
0.084
1.07–2.78
N/A
Hours treating daily: ⬍1 hour vs
1–2 hours
0.93
0.55–1.56
1.65
0.91–3.00
⬎2 hours
2.51
1.53–4.12
2.14
1.18–3.88
1.72
1.04–2.84
Work schedule⫽full vs part time
Vignette type: FUI community vs
N/A
N/A
SUI acute care
0.69
UUI rehabilitation
1.86
1.11–3.12
1.93
1.08–3.44
University teaching⫽yes
OR indicates odds ratio.
N/A
0.36–1.31
2750
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October 2007
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it is a strong predictor of functional recovery and discharge
destination.
In addition, PTs and OTs spending ⬎2 hours treating
stroke patients daily and PTs working full time versus part
time were more likely to be best-practice UI assessment
users, suggesting that those with greater stroke treatment
experience may be more attuned at assessing for UI poststroke sequelae.
Moreover, in each of the 4 logistic models, predictors
related to education, such as opportunities for continuous
learning, university teaching, and student placement, were
associated with higher use of best practices. Finally, working
in Ontario, a province that has stressed continuing education
for clinicians through various strategies including the Ontario
Stroke Strategy and where there is a large critical mass of
OTs and PTs, was associated with the use of best-practice
assessments.
Notwithstanding specific local initiatives, there is evidence
that rehabilitation professionals generally receive little UI
training. In England,27 88% of 548 OTs stated that they had
a role to play in UI management, but only 35% were
assessing clients and ⬍23% received a continence-related
curriculum during training. A 1998 Canadian survey28 of PT
programs found that UI was taught in 81% of these but with
an average of only 1 to 2 hours of theory. A more recent
Canadian survey of 11 of 13 PT programs and 10 of 12 OT
programs (Dumoulin, unpublished data, 2006) suggests this
number has increased: PTs receive, on average, 5.36⫾5.02
hours of primarily theoretical content on UI, whereas OTs
receive, on average, 3.1⫾1.26 hours, with varying ratios of
theory and practice.
Our findings suggest that strategies are needed to encourage clinicians to increase their focus on UI management. The
introduction of a structured assessment model would likely be
a good starting point. The International Classification of
Functioning, Disability and Health model of functioning and
disability,29 with its 3 subdivisions (body structure and
functioning, activities and participation, and environmental
factors), may prove helpful in framing a patient assessment
model, from specific body structure issues related to reduced
pelvic floor muscle strength and tone associated with SUI to
environmental factors such as toilet accessibility, and wheelchair and bed restraints that result in FUI. If clinicians are to
change their UI-related practices, they need easy access to the
emerging evidence.
Potential Limitations
A study using vignettes may overestimate or underestimate
UI management. However, vignettes have been shown to be
a valid means of determining actual practice; indeed, they are
more accurate than chart abstraction.30 Also, given the random sampling and high rate of participation, it is likely these
study findings can be generalized across Canada.
The fact that each UI type vignette was used in association
with only 1 setting (SUI acute care, UUI rehabilitation, and
FUI community) did not allow analysis of the interaction
between UI type and setting. Given an ideal research design,
we could have studied the clinician practices for the 3
different types of UI in the 3 different settings: the sample
size needed would have grown to roughly 600 per site. It
would be interesting to pursue this line of questioning in
future studies.
In conclusion, Canadian OTs and PTs do not routinely
identify poststroke UI as a problem, and best-practice assessments and interventions are underused, which is unfortunate,
given the emerging evidence that UI can be favorably
affected by a multidisciplinary approach. Overall, there is a
need for strategies aimed at improving UI management by
these 2 groups.
Acknowledgments
We acknowledge the support of Dr Julie Lamoureux for statistical
analysis, Anita Menon-Nair for coordination efforts, and the clinicians who participated. We also acknowledge the investigators of
this project for their collaboration: S. Wood-Dauphinee, R. Teasell,
J. Hanley, J. Desrosiers, F. Malouin, A. Thomas, M. Harrison, F.
Kaizer, and E. Kehayia.
Sources of Funding
C. Dumoulin was funded by a postdoctoral award, and N. KornerBitensky and C. Tannenbaum by career awards from the Fond de la
Recherche en Santé du Québec. This project was funded by the
Canadian Stroke Network, the Réseau Provincial de recherche en
adaptation réadaptation, and the Centre de recherche interdisciplinaire en réadaptation du Montréal Métropolitain.
Disclosures
None.
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Urinary Incontinence After Stroke. Identification, Assessment, and Intervention by
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Chantale Dumoulin, Nicol Korner-Bitensky and Cara Tannenbaum
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