Stress urinary incontinence (SUI) affects up to 1 in 3 women globally and is a major contributor to decreased quality of life, social withdrawal, and even depression in otherwise healthy individuals (Bo et al., 2017). As physiotherapists, we are often the first non-surgical, non-pharmacologic point of contact for these patients. With increasing evidence supporting pelvic floor muscle training (PFMT) as a first-line intervention, this article summarizes key findings from high-quality randomized controlled trials (RCTs) that position physiotherapy as an essential part of multidisciplinary SUI care. Defining SUI and Its Clinical Impact SUI is characterized by involuntary urine leakage during effort or physical exertion, such as coughing, sneezing, laughing, or exercising (Haylen et al., 2010). Though often considered a “normal” part of aging or childbirth, untreated SUI leads to avoidable complications, including: Reduced physical activity Increased fall risk in elderly women Sexual dysfunction Higher risk of urinary tract infections For physicians managing this condition, timely referral to physiotherapy can significantly improve patient outcomes and reduce long-term costs. Pelvic Floor Muscle Training: The Gold Standard in Conservative Management A large body of RCTs supports PFMT as the gold standard non-invasive treatment for SUI. In a landmark RCT by Dumoulin et al. (2018), women randomized to supervised PFMT showed a 56% cure rate and a 74% improvement rate, significantly outperforming the control group. This study emphasized the importance of supervision by trained pelvic physiotherapists for optimal outcomes. Another meta-analysis of 31 RCTs involving 1,817 women by Woodley et al. (2020) confirmed that PFMT increases the likelihood of cure or improvement (RR 8.38, 95% CI 3.68–19.07) compared to no treatment or placebo. The findings led to PFMT being recommended as a Grade A recommendation by the International Continence Society and European Association of Urology. Biofeedback and Adjunct Therapies: Enhancing Results Biofeedback devices are commonly used to facilitate neuromuscular control, and their efficacy is supported by several RCTs. Glazener et al. (2011) conducted a multicenter trial with 600+ participants and found that adding biofeedback improved adherence and muscle isolation skills, though long-term differences in outcomes were modest. For patients struggling with proprioception or technique, biofeedback remains a useful adjunct, especially in the early stages of therapy. Other adjuncts include vaginal weights, electrical stimulation, and behavioral therapies. While none of these outperformed PFMT alone in most RCTs, they offer additional options for patients who fail to progress with exercises alone (Berghmans et al., 2013). PFMT vs. Surgical Options: When to Refer While mid-urethral slings remain the gold standard for surgical management, many patients prefer to exhaust conservative options first, especially in cases of mild to moderate SUI. According to a Cochrane review (2017), physiotherapy can delay or avoid surgery in up to 65% of cases when followed consistently over 3–6 months. Moreover, post-operative physiotherapy helps in strengthening the pelvic support structures and preventing recurrence or complications. Therefore, physiotherapy is relevant before and after surgical management. Physician-Physiotherapist Collaboration: What We Need From You For optimal outcomes, physicians are encouraged to: Refer patients early when symptoms appear, rather than after years of discomfort. Share relevant obstetric, surgical, or urological history to aid our evaluation. Encourage adherence to home exercise programs, as this is a major predictor of success. Collaborate on complex cases (e.g., mixed incontinence, pelvic organ prolapse, or prior pelvic surgery). Conclusion and Key Takeaway Stress urinary incontinence is not just a “nuisance” — it is a treatable medical condition with profound quality-of-life implications. Physiotherapists play a critical role in conservative management, and early referral can result in high cure rates without the need for surgery or medication. Physicians who collaborate with pelvic floor physiotherapists provide patients with a holistic, evidence-based approach that aligns with global best practice guidelines. Key References: Bo, K., Hilde, G., & Stær-Jensen, J. (2017). Physiotherapy for female stress urinary incontinence: A review of randomized controlled trials. International Urogynecology Journal, 28(6), 887–899. https://doi.org/10.1007/s00192-017-3362-9 Dumoulin, C., Cacciari, L. P., & Hay-Smith, E. J. C. (2018). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, 10, CD005654. https://doi.org/10.1002/14651858.CD005654.pub4 Glazener, C. M. A., et al. (2011). Pelvic floor muscle training and biofeedback for the treatment of stress urinary incontinence: A multicentre randomized controlled trial. BMJ, 342, d373. https://doi.org/10.1136/bmj.d373 Haylen, B. T., et al. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourology and Urodynamics, 29(1), 4–20. https://doi.org/10.1002/nau.20798 Woodley, S. J., et al. (2020). Pelvic floor muscle training for urinary incontinence in women: Cochrane systematic review and meta-analysis. BJOG, 127(10), 1281–1293. https://doi.org/10.1111/1471-0528.16214 Berghmans, B., et al. (2013). Electrical stimulation with non-implanted electrodes for overactive bladder in adults. Cochrane Database of Systematic Reviews, 6, CD010098. https://doi.org/10.1002/14651858.CD010098.pub2
Overactive Bladder (OAB): A Clinical Overview for Referring Clinicians
Overactive Bladder (OAB): A Clinical Overview for Referring Clinicians Overview: Overactive bladder (OAB) is a symptom-based syndrome characterized by urinary urgency, usually accompanied by frequency and nocturia, with or without urge incontinence, in the absence of UTI or other overt pathology (ICS, 2002). It affects approximately 30% of adults over 40 and becomes increasingly prevalent with age (Hsu et al., 2019). Etiology and Pathophysiology While detrusor overactivity is the urodynamic correlate in many cases, OAB can also occur due to: Neurological disorders (e.g., MS, Parkinson’s) Impaired bladder compliance Pelvic floor dysfunction (hypertonic or hypotonic) Psychological factors (e.g., anxiety, trauma history) Iatrogenic causes (e.g., medications, radiation) Notably, Fontaine et al. (2021) emphasized that detrusor overactivity is not present in all OAB cases, necessitating a broader diagnostic lens. Initial Management: First-Line Conservative Interventions According to current guidelines and high-quality randomized trials, behavioral and physiotherapeutic interventions are the cornerstone of initial management. 1. Bladder Retraining: Evidence supports scheduled voiding with progressive delay intervals, combined with urge suppression strategies (Scaldazza et al., 2017). Techniques include reverse Kegels, diaphragmatic breathing, sensory distraction, and pelvic floor relaxation. 2. Pelvic Floor Physiotherapy: Pelvic health physiotherapists assess and rehabilitate both hypertonic and hypotonic pelvic floors. Contrary to popular assumptions, many OAB patients present with tight pelvic floor musculature that exacerbates urgency/frequency symptoms. 3. Lifestyle Modifications: Elimination of bladder irritants (e.g., caffeine, alcohol, acidic foods) Managing constipation Fluid management and pre-bedtime voiding Supine leg elevation in patients with peripheral edema These non-invasive measures have high patient adherence and low adverse event profiles, making them ideal first-line strategies, particularly in older adults or those with polypharmacy concerns. Pharmacological Interventions If conservative measures prove insufficient, consider the following pharmacologic options: Anticholinergics (e.g., oxybutynin, solifenacin): Effective but associated with dry mouth, constipation, and cognitive risk, especially in the elderly (Welk & McArthur, 2020). β3-Adrenergic Agonists (e.g., mirabegron): Similar efficacy with improved CNS safety profile; preferred in patients at risk for anticholinergic burden (Yamaguchi et al., 2014). Medication adherence is often suboptimal due to side effects, with >50% discontinuing within 6 months (Benner et al., 2010). Combination therapy with behavioral interventions improves outcomes. Advanced Options for Refractory Cases If pharmacological and behavioral therapies fail: Percutaneous Tibial Nerve Stimulation (PTNS): Effective for OAB symptom reduction with a favorable safety profile (Keller et al., 2017). Botulinum Toxin A Injections: FDA-approved for refractory OAB but requires intermittent self-catheterization in some patients. Sacral Neuromodulation: Considered in severe cases with mixed incontinence or when other modalities fail. Referral Recommendations Refer patients for pelvic floor physiotherapy when: Symptoms persist despite lifestyle changes Pelvic floor dysfunction is suspected (e.g., concomitant pelvic pain, constipation) Pharmacologic therapy is contraindicated or declined Patients prefer non-invasive, functional approaches Conclusion for Clinical Practice OAB is a multifactorial condition with a significant impact on quality of life. Evidence-based management emphasizes a stepwise approach beginning with behavioral therapy and physiotherapy, progressing to pharmacological and neuromodulation therapies as needed. Collaborative care involving physiotherapists, urologists, and family physicians ensures optimal outcomes. Key References Benner, J., Nichol, M., Rovner, E., Jumadilova, Z., Alvir, J., Hussein, M., & Brubaker, L. (2010). Patient‐reported reasons for discontinuing overactive bladder medication. BJU International, 105(9), 1276–1282. https://doi.org/10.1111/j.1464-410x.2009.09036.x Fontaine, C., Papworth, E., Pascoe, J., & Hashim, H. (2021). Update on the management of overactive bladder. Therapeutic Advances in Urology, 13, 17562872211039034. https://doi.org/10.1177/17562872211039034 Hsu, Y. P., Chuang, F. C., Chang, S. J., & Yang, S. S. (2019). Prevalence and associated factors of overactive bladder among the elderly in Taiwan. International Urogynecology Journal, 30(7), 1091–1099. https://doi.org/10.1007/s00192-018-3776-4 Keller, N., Schmid, S., & Haemmerle, B. (2017). Successful therapy of overactive bladder syndrome with percutaneous tibial nerve stimulation: A case report. The International Annals of Medicine, 1(11), 387. https://doi.org/10.24087/iam.2017.1.11.387 Scaldazza, C., Morosetti, C., Giampieretti, R., Lorenzetti, R., & Baroni, M. (2017). PTNS vs. pelvic floor muscle training in women with OAB: A randomized study. International Braz J Urol, 43(1), 121–126. https://doi.org/10.1590/s1677-5538.ibju.2015.0719 Welk, B., & McArthur, E. (2020). Dementia risk in patients treated for OAB: Anticholinergic vs beta‐3 agonists. BJU International, 126(1), 183–190. https://doi.org/10.1111/bju.15040 Yamaguchi, O., Marui, E., Kakizaki, H., Homma, Y., Igawa, Y., Takeda, M., & Ohkawa, S. (2014). Mirabegron 50 mg for OAB in Japanese patients: A phase III trial. BJU International, 113(6), 951–960. https://doi.org/10.1111/bju.12649
Subacromial Impingement Syndrome (SIS)
Subacromial Impingement Syndrome (SIS) / Subacromial Pain Syndrome (SAPS) Introduction Subacromial Impingement Syndrome (SIS), now more inclusively termed Subacromial Pain Syndrome (SAPS), remains the leading cause of shoulder pain in primary care, accounting for 44% to 65% of shoulder-related consultations (Umer et al., 2012; Yuan et al., 2022). It encompasses a spectrum of pathologies including rotator cuff tendinopathy, subacromial bursitis, and partial tears, often with overlapping symptoms. As physiotherapists, we emphasize non-surgical management using evidence-based strategies that restore function, reduce pain, and prevent chronicity. Timely referral to physiotherapy can reduce the need for advanced imaging, injections, or surgical intervention. Key Clinical Features Painful arc during shoulder elevation Night pain, particularly when lying on the affected side Tenderness over the subacromial space Positive signs on Hawkins-Kennedy, Neer, and painful arc tests Decreased strength in external rotation and abduction Risk Factors Repetitive overhead activity (occupational or athletic) Postural dysfunction (rounded shoulders, thoracic kyphosis) Sleep disturbances and insomnia (Lv et al., 2024) Psychological components: fear-avoidance, low expectation of recovery (Chester et al., 2010) Conservative Management: Evidence Summary 1. Exercise Therapy A meta-analysis by Hanratty et al. (2012) concluded that structured physiotherapy focusing on rotator cuff and scapular stabilization exercises significantly improves pain and shoulder function. Programs incorporating eccentric loading, neuromuscular control, and postural correction outperform general exercise protocols. 2. Manual Therapy and Neuromobilization Combining manual therapy with exercises improves short-term outcomes and patient satisfaction. Techniques include soft tissue release, joint mobilization, and neural glides. 3. Lifestyle Modification and Sleep Education A 2024 Mendelian randomization study demonstrated that genetic predisposition to short sleep duration and insomnia is associated with a 53–66% increased risk of SIS (Lv et al., 2024). We educate patients on ergonomics, posture, and sleep hygiene as integral parts of care. 4. Shockwave Therapy Effective particularly for calcific tendinopathy, ESWT has shown positive results in pain reduction and calcium deposit resorption (Xie et al., 2023). Its benefit for non-calcific SIS remains limited. 5. Psychological Support Fear-avoidance behaviors and catastrophizing are barriers to recovery. Patient education and graded exposure are integrated into treatment plans. When to Refer to Physiotherapy Persistent shoulder pain > 2 weeks with overhead movements Night pain interfering with sleep Decline in function or work capacity Suspected SIS without red flags or full-thickness rotator cuff tear When to Consider Imaging or Injections Symptoms persist beyond 6 weeks with no improvement despite physiotherapy Suspicion of full-thickness tear or significant structural pathology Diagnostic uncertainty (ultrasound preferred over MRI in early phases) Outcomes and Prognosis With early physiotherapy, most patients demonstrate significant improvement within 6–12 weeks. Surgical intervention, including subacromial decompression, shows no superior long-term outcomes when compared to conservative care (Lähdeoja et al., 2020). Referral Pathway We offer evidence-informed rehabilitation programs tailored to the specific needs of each patient. Our assessments include: Detailed postural and functional analysis SPADI scoring to track progress Education on modifying aggravating activities and sleep habits Progressive exercise prescription, manual therapy, and, where indicated, shockwave therapy Physicians may refer patients directly to our clinic by fax or by having patients contact us directly. We are happy to collaborate and share outcome updates upon request. References Chester, R., Smith, T. O., Hooper, L., & Dixon, J. (2010). The impact of subacromial impingement syndrome on muscle activity patterns of the shoulder complex: A systematic review of EMG studies. BMC Musculoskeletal Disorders, 11, 45. https://doi.org/10.1186/1471-2474-11-45 Hanratty, C. E., McVeigh, J. G., Kerr, D. P., Basford, J. R., Finch, M. B., Pendleton, A., & Sim, J. (2012). The effectiveness of physiotherapy exercises in subacromial impingement syndrome: A systematic review and meta-analysis. Seminars in Arthritis and Rheumatism, 42(3), 297–316. https://doi.org/10.1016/j.semarthrit.2012.01.005 Lähdeoja, T., Karjalainen, T., Jokihaara, J., et al. (2020). Subacromial decompression surgery for adults with shoulder pain: A systematic review with meta-analysis. British Journal of Sports Medicine, 54(11), 665–673. https://doi.org/10.1136/bjsports-2019-101333 Lv, Z., Cui, J., Zhang, J., & He, L. (2024). Lifestyle factors and subacromial impingement syndrome of the shoulder: potential associations in Finnish participants. BMC Musculoskeletal Disorders, 25, 220. https://doi.org/10.1186/s12891-024-07345-w Xie, X., Ma, J., Feng, H., & Zhang, Y. (2023). Effectiveness of extracorporeal shockwave therapy for rotator cuff tendinopathy: A systematic review and meta-analysis. BMC Musculoskeletal Disorders, 24, 189. https://doi.org/10.1186/s12891-023-06345-3 Let’s Work Together If you’d like to refer a patient or request a case discussion, please contact Noshin’s Physiotherapy. Our goal is to provide high-quality, individualized care to support your patient’s recovery and long-term outcomes.