Introduction

Urinary incontinence (UI), defined as the involuntary loss of urine, is a health problem that significantly impacts social interactions, interests, and emotional well-being [1]. In physiotherapy, one of the conservative treatments for UI involves exercise programs aimed at restoring the function of pelvic floor muscles (PFMs) based on their specific requirements. It has been suggested that pelvic floor muscle training (PFMT) should be included in a primary care program for women experiencing different types of incontinence [2]. Despite the positive gains of PFMT, it is noteworthy that studies utilize exercises with varying sets, repetitions, intensity, and duration, and there is no consensus on the exercise protocol among researchers [3]. In addition, considering the relationship between the diaphragm and the PFMs during respiration, as well as the synergistic co-contractions between the transversus abdominis and the PFM, some researchers suggest that it might be beneficial to incorporate diaphragmatic breathing and core exercises into PFMT for UI [4]. The exercise training programs for UI can be conducted either individually or in groups. Compared with individual training, group training programs are a cost-effective technique for treating pelvic floor dysfunction [5].

The use of information and communication technologies in the delivery of rehabilitation services is known as telerehabilitation (TR) [6]. In the implementation of TR applications, synchronous, asynchronous, or hybrid programs can be preferred [7]. TR applications have been reported to be beneficial to women with UI [8]. There are studies in the literature comparing the effectiveness of training applied through the TR method with conservative face-to-face training [8]. However, no study has been found comparing the effects of different hybrid exercise programs.

The aim of our study is to evaluate the effect of a new and comprehensive progressive training program (PTP), including PFMT, diaphragmatic breathing exercises, and core exercises, in the form of individual and group hybrid training, on incontinence-related parameters in women with UI and to compare them with each other.

Materials and Methods

Design

The study was a two-arm, parallel-group, randomized trial with concealment of allocation and intent-to-treat (ITT) analysis. The research was conducted in a tertiary-level public hospital between 30 November 2021, and 1 July 2023. Women who were determined to be suitable for participation after examination by a uro-gynecologist were invited to the study. Participants were randomly allocated via a computer-generated random number program for individual hybrid training, or group hybrid training. The exercise training began immediately following the evaluation in individual hybrid training whereas it began when there were eight participants in the group hybrid training.

Participants

The inclusion criteria are women between the ages of 18 and 65 with stress or mixed (predominantly stress urinary incontinence [SUI]) UI, mild to moderate SUI (the degree of incontinence is determined according to the Stamey Classification [9]; mild SUI: leakage from coughing, sneezing, laughing, or any physical activity; moderate SUI: incontinence with carrying, pushing, lifting, walking, and any light physical activity), and having a body mass index of 18–30 kg/m2. The exclusion criteria were pregnancy, ongoing vulvovaginitis, urinary tract infection, any malignity (to ensure group homogeneity regarding general health status), PFM strength 0–1 according to the Modified Oxford Scale, previous surgery for SUI, visual problems or inability to understand given commands, conservative treatment for UI in the last 6 months, grade II and higher pelvic organ prolapse according to the Pelvic Organ Prolapse Quantification System classification, musculoskeletal problems that will prevent them from exercising, and women who do not have access to the necessary facilities for telerehabilitation.

The suitability of all participants for the study was determined following examination by the urogynecologist involved in clinical care (who was also a research physician). Evaluation and outcome measurements for patients who met the inclusion criteria were conducted by the researcher, a physiotherapist.

Ethical approval was obtained from the Scientific Research Ethics Committee of the Faculty of Medicine of Marmara University (approval date and number: 30.11.2020/09.2021.1195). This study was conducted in compliance with the Declaration of Helsinki (Clinical Trial Registry Number: NCT05154760). Informed consent forms were obtained from all participants before participation.

Interventions

Both groups were instructed to continue a PTP at least 4 days a week for 8 weeks. Synchronous training was designed using the video call features of the Telegram and WhatsApp applications. Exercise follow-up charts were used to determine the continuity of all participants.

Individual Hybrid Training

Volunteers in the IHT group continued IHT throughout the 8-week program. The PTP was carried out on the same day of the week with one session per week (1st day of the week) synchronous video conference method and at least three sessions per week asynchronously. In the synchronous training session, the physiotherapist demonstrated the exercises herself while the participant performed the exercises with her. A physiotherapist provided necessary warnings and corrections if a participant performed the exercises incorrectly. Once it was confirmed that the patients performed the exercises correctly, participants engaged in weekly asynchronous training. The asynchronous exercises were carried out on predetermined days and times according to the preferences of the participants, using the video series regarding the training program. Moreover, illustrated and explanatory brochures of the exercises learned in the synchronous session were distributed to the patients. Thus, patients were encouraged to remember the exercises and perform them correctly. During the monthly face-to-face evaluations, all exercises were reviewed again with the participant. The physiotherapist also followed each exercise phase of the asynchronous training program through the weekly program chart. In a weekly synchronous training session, the physiotherapist reminded the participants of each new and ongoing exercise. Participants were also requested to consult a physiotherapist if they had any questions.

Group Hybrid Training

The GHT group received PTP in groups of eight and, similar to IHT, underwent a progressive muscle training program that included pelvic floor exercises. The GHT group received training via synchronous video conferencing for one session per week (1st day of the week) and asynchronous video conferencing for at least three sessions per week, with the simultaneous participation of all patients. In this group, the physiotherapist demonstrated the exercises during the synchronous training session while the participants performed the exercises under the supervision of a physiotherapist. At the end of the synchronous training session, the question–answer session was completed. The physiotherapist provided necessary warnings and corrections if participants performed the exercises incorrectly. Once it was confirmed that the patients performed the exercises correctly, participants engaged in weekly asynchronous training. The asynchronous exercises were carried out on predetermined days and times according to the preferences of the participants, using the video series regarding the training program. Moreover, illustrated and explanatory brochures of the exercises learned in the synchronous session were distributed to the patients. Thus, patients were encouraged to remember the exercises and perform them correctly. The physiotherapist followed each exercise phase of the asynchronous training program through the weekly program chart. In a weekly synchronous training session, the physiotherapist reminded the participants of each new and ongoing exercise.

Progressive Training Program

The PTP used in this study included PFMT, diaphragmatic breathing exercises, and core exercises (Appendix Table 4).

  • PFMT: before the evaluation, participants were provided with general information about the pelvic floor. The participants were instructed how to contract the PFM correctly using a digital palpation technique in the lithotomy position following the briefing, and then the exercises were explained. In order to create the PFMT protocol, the study by Özlü et al. [10] was used as a reference for slow contractions, whereas exercises consisting of fast contractions were also included. Exercises were performed in standing, sitting, and supine positions.

  • Diaphragmatic breathing exercise: owing to the synergistic relationship between the muscles of the pelvic floor and those of the diaphragm, diaphragmatic breathing exercises were included in the program. After inspiration, participants were asked to perform PFM contractions with expiration. The exercises were performed in three sets of eight to ten repetitions in standing, seated, and supine positions.

  • Core exercises: the core exercises consist of basic exercises that strengthen both global and local muscles. Participants were asked to perform PFM contractions slowly and in a manner that would activate type I fibers along with core exercises. In the first 4 weeks, core exercises were performed in two sets of eight repetitions, whereas in the last 4 weeks, they were performed in three sets of eight repetitions.

Bladder Training

We provided bladder training to the participants in order to decrease their frequency of urination and increase their bladder capacity. Participants were evaluated in their usual routines. Subjects who agreed to participate in the program were instructed to maintain their regular fluid intake during the research. From the bladder diary, in which participants recorded their urination times in one day, the most frequent repetitive urination interval was identified. In the 1st week, participants were asked to urinate by increasing this determined interval by 15 min. When the goal was achieved, she was instructed to extend the time by 15 min each week. When the weekly target was not met, this period was left unchanged.

Outcomes

Physiotherapists evaluated participants before the intervention, at the end of the 4th week, and at the end of the 8th week by face-to-face meeting. Patients' age, height, weight, body mass index, menopause status, number and type of births, diseases, and surgical histories were recorded in the patient evaluation form before the evaluation.

Primary Outcomes

PFM Function

Function of the PFM was evaluated in the lithotomy position by digital palpation according to the Power, Endurance, Repetitions, Fast contractions, and Every Contraction Timed (PERFECT) scheme and surface electromyography (sEMG).

  1. 1.

    PERFECT scheme: the PERFECT scheme was used to evaluate the function of the PMFs [11]. Using the digital palpation technique, the index finger was inserted into the participant's vagina up to the proximal interphalangeal joint with gloves and lubricant gel. We graded the P value between 0 and 5 using the Modified Oxford Scale, the E value was recorded in seconds, and the number of repetitions was recorded for slow (R) and fast (F) contractions. The measurements were repeated three times, and the average was calculated.

  2. 2.

    sEMG: the NeuroTrac Myoplus Pro (Quintet, Bergen, Norway) sEMG device evaluated PFM function objectively. The disposable 30 × 30 mm round adhesive electrodes (Verity Medical Ltd., Braishfield, UK) were attached to the area, which was cleaned with alcohol and was free of hair. Two electrodes were placed on the right and left sides of the vaginal opening, and a reference electrode was placed on the inner thigh [12]. Three 10-s contractions were performed by participants, with a 20-s rest interval between contractions. The resting tone, work average, and peak force were measured in microvolts and the maximal voluntary contraction (MVC) in percent. Participants were given verbal and voice commands during the evaluation. The participants were warned not to hold their breath or use their abdominal, hip, or leg muscles.

3-day Bladder Diary

The 3-day bladder diary is used to see the decrease in incontinence severity and the effectiveness of intervention after treatment [13]. They were asked to record the daytime urination frequency, nocturnal urination frequency, urinary incontinence frequency, urinary urgency frequency, and fluid intake during the first 3 days of beginning treatment, 3 days after the 4th week of evaluation, and 3 days after the end of the treatment. A chart was given to the patient for easy follow-up.

Secondary Outcomes

Quality of Life

The International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) and the Incontinence Impact Questionnaire (IIQ-7) were used to evaluate the quality of life related to symptoms. The Turkish validity and reliability studies were conducted for both questionnaires [14, 15].

Symptom Scales

The Urogenital Distress Inventory—6 (UDI-6) was used to assess UI symptoms and quality of life. An eight-item Overactive Bladder Questionnaire (OAB-V8) was used to assess symptoms of overactive bladder. The cut-off value for the questionnaire is 11, and Turkish validity and reliability studies were conducted for both questionnaires [15, 16].

Exercise Adherence

The Broome Pelvic Muscle Self-Efficacy Scale was used to assess participants’ adherence and their sense of self-efficacy. It consists of two sub-dimensions: efficacy expectations and outcome expectations. The Turkish validity of the scale has been established [17].

Data Analysis

Consolidated Standards of Reporting Trials (CONSORT)'s non-inferior randomized trials guidelines were followed in the sample size analysis [18]. At the beginning a pilot study was conducted with 20 people. The “Power” (P) parameter, one of the primary outcome measurements, was used in the sample size analysis. The 20% difference between IHT and GHT in the P parameter was determined to be the non-inferiority margin [19]. The sample size was calculated assuming that the effects of the GHT were not inferior to those of the IHT and the difference between them would be 0 for 90% power at 95% CI, α = 0.05. In the pilot study we conducted, the standard deviation of the P value was determined to be 25% from the intra-group analysis of the IHT and was used in the calculation. By accessing https://riskcalc.org/samplesize/ [20] via the Internet, it was determined that there should be at least 22 people in each group, considering 10% data loss.

Analyses were performed by an independent statistician who was blinded to group allocation using the SPSS 22.0 statistics package (IBM SPSS Statistics for Windows, Version 22.0, IBM Corp., Armonk, NY, USA). The Shapiro–Wilk test and histograms were used to analyze the normal distribution of variables. The continuous data were presented as mean ± standard deviation. The categorical data were presented as a number and a percentage (%). We conducted an ITT analysis to determine the effect of training and the differences between the groups. The analysis was conducted using an independent t test to determine if there were differences in the initial data. For all subsequent analyses, a mixed-effect repeated measures ANOVA test was utilized to maintain the confidence interval. Post hoc testing with Bonferroni correction was employed to identify intra-group changes. The effect sizes were expressed as partial eta-squared values (η2p; small ≥ 0.01, medium ≥ 0.06, large ≥ 0.14). Statistical significance was accepted at an α level of 0.05. Cohen's d was used to calculate effect sizes by subtracting the mean change over time (baseline to 8th week) for the IHT from the mean change for the GHT, then dividing the result by the pooled standard deviation [21].

The outcomes of the 8-week PTP were also evaluated based on the minimal clinically detectable importance (MCID) for PERFECT scheme parameters, ICIQ-SF, IIQ-7, UDI-6, and 3-day bladder diary parameters. A reduction of 20% in P, E, R, F values is considered to be the MCID [19]. A change of at least 4, 16, and 11 points in ICIQ-SF, IIQ-7, and UDI-6 scores respectively are determined to be the MCID [22, 23].

Results

An evaluation was conducted on 115 patients who applied to the clinic during the research period. A total of 65 patients were excluded from the study owing to noncompliance with the inclusion criteria. Eighteen participants who were given baseline measurements and participated in the exercise groups withdrew from the study for nonresearch reasons. These participants were included in the ITT analysis (Fig. 1).

Fig. 1
figure 1

The Consolidated Standards of Reporting Trials (CONSORT) flow diagram

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The socio-demographic data and baseline measurements of the participants who completed the whole process and dropped out of the study are shown in Table 1.

Table 1 Participants' characteristics at baseline
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Primary Outcomes

Pelvic Floor Muscle Function

Within-group and between-group comparisons of PFM function evaluated using the PERFECT scheme and sEMG are shown in Table 2.

Table 2 Comparison of the pelvic floor muscle parameters of the two groups
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PERFECT Scheme

After the training program, in the PERFECT scheme where we evaluate pelvic floor muscle strength determined improvement in both groups. Pelvic floor muscle power (P), muscle endurance (E), and the number of maximal voluntary contraction repetitions for slow (R) and fast (F) contractions that show PMF function demonstrated statistically significant improvements in the two groups (p < 0.001). In the comparison of the groups, there was a significant improvement in favor of GHT only in the power parameter (F: 3.535; p < 0.05; η2p: 0.124). Accordingly, the effect size for P was determined to be small for the baseline and 8-week measurements (Cohen’s d = 0.33).

Participants who achieved MCID for P, E, R, and F at baseline to the 4th week (T0), baseline to the 8th week (T1), and the 4th week to the 8th week (T2) were especially noteworthy at T1. The rate of reaching MCID showed an increasing trend over time in both groups. At the 4th week, this rate varied between 50% and 92.3% in both groups for the parameters evaluated. At the end of the 8th week, the rate of reaching MCID was between 53.8% and 100% (Fig. 2).

Fig. 2
figure 2

The percentages of participants with minimal clinically detectable importance (MCID) in P, E, R, F, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), and Incontinence Impact Questionnaire (IIQ-7)

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Surface Electromyography

In both groups, there were significant improvements in pelvic floor muscle function. especially work average and peak force parameters (p < 0.001, for both parameters) increased in the two groups; however, the MVC% value only exhibited significant improvements in the IHT group (p < 0.001). There was no significant difference in the resting tone parameter between the two groups (p > 0.05). In comparisons between the two groups, sEMG parameters did not show statistically significant differences.

Three-day Bladder Diary

In the group analysis, significant improvements were observed in all parameters for both groups, except for the frequency of daytime and nocturnal urination in the IHT group (p < 0.001). In the comparison between the groups, a significant difference was found in favor of GHT in nocturnal urination frequency (F: 3.557; p = 0.036, η2p: 0.125). The percentages of participants reaching the MCID for nocturnal urination frequency in the groups were as follows: in the IHT group, 25% and 55.16% at T0 and T1 respectively; in the GHT group, 42.30% and 73.07% respectively.

Secondary Outcomes

The within-group and between-group comparisons of the secondary outcome analyses of the participants are shown in Table 3.

Table 3 Comparison of the two groups’ outcomes
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Quality of Life

Both groups showed statistically significant improvements in the ICIQ-SF and IIQ-7 total scores (p < 0.001). Although there was a significant difference in favor of GHT when ICIQ-SF and IIQ-7 scores were compared at the end of the 4th week (p < 0.05), no statistically significant difference was detected between the groups at the end of 8 weeks (p > 0.05).

Based on the number of cases reaching MCID, the improvement rates for secondary outcomes were also examined. The proportion of the participants who achieved MCID for ICIQ-SF was remarkable at T2 (84.6% vs 53.8%) for the IHT. The rate of cases with IIQ-7 MCID was remarkable in the IHT group, especially during the T2 period (61.5% and 38.5% respectively). Figure 2 illustrates the proportions of participants who achieved MCID in both groups for the ICIQ-SF and IIQ-7.

Symptom Scales

Both groups showed statistically significant improvements in the UDI-6 total scores (p < 0.001). In the comparisons of the two groups, no significant differences were found (p > 0.05). Based on the number of cases reaching MCID, the improvement rates for secondary outcomes were also examined. The proportion of participants with MCID for UDI-6 in the IHT group was 65.4% in T0, whereas it was 30.8% in the GHT group. Figure 3 illustrates the proportions of participants who achieved MCID in both groups for the UDI-6.

Fig. 3
figure 3

The percentage of participants with minimal clinically detectable importance in Urogenital Distress Inventory—6 (UDI-6), the percentage of participants who scored above the cut-off value in Eight-item Overactive Bladder Questionnaire (OAB-V8), and the percentage of participants according to pelvic floor self-efficacy level

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Overactive bladder symptoms that we questioned with the OAB-V8 total score had decreased statistically significantly in the IHT group at the 4th week (p < 0.05) and in both groups at the 8th week (p < 0.001). In the comparisons between the groups, no statistically significant difference was observed (p > 0.05). Figure 3 illustrates the percentage of participants who scored above the OAB-V8 cut-off value. At the end of the 8th week, the percentage of participants who scored above the cut-off value had decreased in both groups.

Exercise Adherence

Statistically significant differences were observed in the Broome pelvic floor muscle self-efficacy scale total scores in the IHT group (p < 0.05), but there were no significant differences in the GHT group (p > 0.05). Comparisons between the two groups did not reveal any statistically significant differences (p > 0.05). It is noteworthy that the number of participants with the highest self-efficacy levels was reached at the end of the 8th week in both groups (Fig. 3).

Discussion

In this study, in which we compared the effects of IHT and GHT in women with UI, GHT provided a greater increase in P value measurements and a greater decrease in nocturnal urination frequency. Both types of training showed beneficial effects on PFM function, quality of life, exercise adherence, and other parameters related to incontinence, like other studies that applied face-to-face training.

In PFMT, the goal is to promote the effective, voluntary, and autonomic function of the muscles within the pelvic floor. Garcia-Sánchez et al. [3] stated that PFMT in short sessions of 10–45 min, 3–7 days a week can lead to a significant change in women with SUI; they recommended that the program be applied for at least 6 weeks, fast and slow twitch fibers should be exercised, and rest periods of 1–3 min should be given to achieve recovery. The PFMs function synergistically with the diaphragm and abdominal muscles to regulate respiration and intra-abdominal pressure. We created our PTP, which gives a unique feature to our study, based on all this information in the literature, including PFMT, diaphragmatic breathing exercises, and core exercises, and applied it to our participants for 8 weeks. We aimed to get maximum efficiency from the exercises by working the pelvic floor and related muscle groups. As women with mixed incontinence were also included in the study, we aimed to reduce the frequency of urination and increase the capacity to retain urine by giving the participants bladder training.

In our study, we used assessments based on objective and participant reporting (PERFECT Program, sEMG, and 3-day bladder diary) to assess PFM function. Studies that used the same evaluation techniques have shown different results [24, 25]. In our study, at the end of the 4th week and 8th weeks, it was observed that PTP provided an increase in PFM strength with P, E, R, and F parameters in both groups. Based on the comparison of the gains between the two groups, the GHT resulted in a significant increase in the P parameter. Also, the improvements in the P value were reflected in the results of the MCID. A total of 30.8% of participants who received IHT and 46.2% of those who received GHT reached the MCID after 8 weeks. A difference in the P values expressed in the literature can be attributed to differences in the applied method and practitioner. Although the vaginal palpation technique and PERFECT scheme provide flexibility and reduce uncertainty in the person evaluating in the clinical environment, it is a subjective method. It has been reported that it cannot discriminate muscle strength accurately compared with pressure measurements [11, 26]. For this reason, sEMG was also used to evaluate PFMs. In the 4-week and 8-week results of both groups it was determined that there were improvements in the work average and peak strength; although there were improvements in the %MVC, it was determined that this improvement reached the level of significance in the IHT group. To our knowledge, no studies have been found in the literature comparing individual and group training and evaluating PFM activation with sEMG. The differences in the results we obtained using digital palpation and sEMG may be caused by the two methods evaluating different muscle-related factors. Although muscle strength is evaluated using the modified Oxford scale, information about the activation of muscle fibers is obtained using sEMG [27].

At the end of 8 weeks, it was determined that the improvements in daytime urination, urinary incontinence, and urinary urgency were similar in the two groups. This situation supports the results of face-to-face individual and group training in the literature [28]. When the results at 4 weeks are evaluated, it is noted that this period is not sufficient considering the frequency of daytime urination. On the other hand, although GHT did produce a significant improvement in daytime urination frequency, the results did not differ significantly between the groups. It was determined that GHT significantly improved nocturnal urination frequency. Methods of treatment that emphasize exercise and respiratory techniques contribute to the reduction of psychological and physiological stress, as well as the regulation of neuroendocrine stress symptoms. One study emphasized that posture, relaxation, and focused breathing used in yoga can regulate the sympatho-vagal tone and reduce inflammation associated with urge UI by decreasing sympathetic tone and increasing parasympathetic outflow [29]. In our study, the PTP contributed positively to both groups in this direction. Behavioral training programs including PFMT and bladder control strategies have been shown to improve nocturia in women with UI [30]. The bladder training, we gave to both groups in our study may have affected the improvement in parameters related to voiding frequency.

There are many factors that can cause nocturia. One of them, anxiety, has been reported to be associated with stress urinary incontinence, and nocturia in women [31]. It states that group training strengthens social interaction and reduces the feeling of loneliness associated with the disease in women with similar problems. This may have affected the frequency of nocturia by reducing the anxiety level. However, as we did not evaluate urinary incontinence from a psychosocial perspective in our study, we cannot make a definitive statement. On the other hand, when we are analyzing the results, we also evaluated all our participants according to the level of clinical significance they achieved, on an individual basis. In the literature, it has been suggested that a reduction of 50% or more in episodes in the presence of stress urinary incontinence or overactive bladder should be considered as a clinically significant improvement [32, 33]. The percentages of participants reaching the MCID for nocturnal urination frequency in the groups were as follows: with IHT, 25% and 55.16% at the 4th week and at 8th week respectively; with GHT, 42.30% and 73.07% respectively. These results also support our hypothesis regarding the benefit of group exercises. However, there is still a possibility that this result is a coincidence. Future research may focus on this issue from a methodological perspective.

Having UI adversely affects a woman's quality of life [34]. According to studies comparing face-to-face individual or group physiotherapy, both groups achieved significant improvements in quality-of-life and symptom scales, and the gains between the groups were similar [25, 35]. Within-group analyses showed improvements in quality-of-life and symptom scales for both groups. In our research, we determined that GHT led to a greater improvement in quality-of-life scores at the end of the 4th week, but this situation equalized at the end of 8 weeks. For this reason, we think that GHT can lead to positive changes in the quality of life in short-term interventions such as at 4 weeks and that it is no different than IHT in longer interventions. At the end of the 8th week, when the MCID values were examined according to the scales evaluating the quality of life, it was observed that the rate of patients who achieved MCID was significantly higher in the IHT group in particular. This result can be attributed to the physiotherapist–patient interaction and the increase in exercise adherence in individual education. Additionally, the improvement in the cases participating in the GHT program could be attributed to the fact that individuals with similar problems focus more on treatment and that intra-group competition increases the effectiveness of the program. When the symptom scales are examined, we think that 4 weeks of training is not enough time to lead to a significant improvement in overactive bladder symptoms in both groups, and the difference we obtained in both groups in the 8-week results supports our opinion.

Using mobile technologies in the treatment of UI has been shown to improve adherence. In our study, in which we compared the effects of IHT and GHT on exercise adherence, we did not find any difference between the groups. Similar results were obtained by Cacciari et al. in their study that compared individual and group training during 12 weeks of PFMT [36]. In the current study, interviewing all groups after the same amount of time and number of sessions, as well as the inclusion of weekly synchronous exercise sessions, may have contributed to the high level of adherence.

To our knowledge, our research is the first study comparing the effects of hybrid application of PTP in women with UI on incontinence-related parameters. It is also, as far as we know, the first study comparing IHT and GHT in UI. Other factors that make our research strong are the facts that we used sEMG in addition to the digital palpation technique when evaluating PFM function and that the statistician who performed our statistical analysis was blinded to the study.

This study has some limitations that should be highlighted. The International Continence Society recommends pad testing to determine the degree of incontinence. Unfortunately, some of the research coincided with the pandemic period. The research was conducted at an institution providing tertiary health care services. To prevent the risk of contamination, the hospital stay of the patients was limited, and we were unable to use the pad test in this research. For this reason, the Stamey Incontinence Severity Classification, a subjective and short method in the literature, was used to determine the degree of incontinence.

Second, the assessor was not blinded to the groups. Because of the pandemic process and busy working conditions, the number of researchers was limited. This could harm the methodological quality. On the other hand, a researcher blinded to the study performed the statistical analysis. We are also aware of the imbalances that may occur between groups due to randomization. As we considered this to be a limitation, the data were evaluated from different aspects in order to minimize the margin of error. The percentage of participants for whom clinical significance was achieved on a personal basis in the parameters was also calculated.

Another limitation is that transperineal sEMG was used instead of intravaginal sEMG in the sEMG measurements owing to our limited research budget.

A cost analysis was not conducted in this study as they were not included in our research questions. Although we predict that GHT may be cost-effective, future studies may also examine this issue. One of our limitations is the inability to blind the physiotherapists who evaluate and patients because of the methodology of the study.

Conclusion

Women with UI who performed PTP in the GHT group for 8 weeks reached better results than in the IHT group, only in terms of P value and night-time urination frequency. There was a significant improvement in within-group results for muscle function, quality of life, exercise adherence, and symptoms related to incontinence; however, there was no significant difference between groups. Group training, which has been shown to be a cost-effective method, can also be applied online via videoconferencing in cases where it is difficult to reach the hospital. However, we believe that more methodologically sound studies are required investigating PTP and assessing how IHT and GHT affect disease-related parameters and costs.