People with spinal cord injury (SCI) face multiple health complications to many of the major physiological systems. Impairments in urinary function, secondary to denervation of pelvic structures including the bladder, urethral sphincters, and pelvic floor muscles are a common health concern, with ~80% of people with SCI experiencing neurogenic lower urinary tract dysfunction (1, 2). As the physiological and psychosocial consequences of chronic urinary impairments have serious implications on overall quality of life, it is no surprise that recovery of bladder function is of utmost priority for people with SCI (3, 4).

In able-bodied populations, pelvic floor muscle training (PFMT) is used to treat conditions such as urinary incontinence and sexual dysfunction in both males and females (5–7). This type of training involves practicing various combinations of contracting and relaxing the pelvic floor muscles in order to improve the strength, endurance, and coordination of this muscle group (8, 9). With pelvic floor muscle activation, the muscles squeeze around the urethra and lift upward, while reflexively inhibiting detrusor activity. These mechanisms can be refined through PFMT to improve urinary incontinence and other pelvic disorders (1, 2, 8, 9).

There is some preliminary evidence that PFMT may be used to improve neurogenic lower urinary tract dysfunction and male sexual health in people with SCI (10–12). After engaging in a PFMT program, individuals with SCI have reported less incontinence, fewer episodes of neurogenic detrusor activity, and reduced severity of erectile dysfunction (10–12). However, studies to-date have included relatively small sample sizes and only people with motor-incomplete SCI. There is evidence that despite their clinical diagnosis, people with complete paralysis after SCI are able to voluntarily activate some muscles below their level of injury (13–17), including the pelvic floor muscles (18). Thus, while people with motor-incomplete SCI may be more likely candidates for PFMT, there may also be opportunities to introduce PFMT to the motor-complete SCI population.

PFMT is not commonly prescribed to people with SCI, and the perspectives of this population toward to PFMT remains unknown. Understanding a population's knowledge, attitudes, and practices (KAP) about an intervention can reveal behavior intention toward health outcomes (19, 20). Previous studies that have assessed KAP of PFMT most often included able-bodied pregnant or post-partum females (21–24). These studies demonstrated that many participants were unaware of the benefits of PFMT and were consequently not participating in a PFMT program. Interestingly, despite having minimal knowledge of PFMT, respondents had positive attitudes toward learning more about this therapy and engaging in a PFMT program (21–24). The results from KAP surveys may therefore reveal opportunities to broaden a population's awareness and uptake of a given therapy or exercise program (19).

Although the benefits of PFMT have been predominantly explored in females (5, 8), there are clinical studies demonstrating that PFMT can also treat incontinence and sexual dysfunction in males (7, 25, 26). To date, there is little information on the KAP of males relating to PFMT in either clinical or able-bodied populations. As the majority of the SCI population is male (27, 28), it is also relevant to explore KAP within the context of sex to identify possible differences between the experience and perspectives of males and females.

Given the potential opportunities to explore the benefits of PFMT in the SCI population, and the importance of understanding perspectives on exercise program participation, the primary purpose of this study was to assess the KAP related to PFMT in the SCI population using an online questionnaire. A secondary aim was to explore differences in KAP in people with motor-incomplete vs. motor-complete SCI, and males vs. females with SCI. This information can be used to inform health practitioners and aid designers of PFMT programs specifically for the SCI population.

Data for this study were collected using an online survey (29). Prior to distribution, we sought feedback on a draft version of the survey from a small group of knowledge-users, including two clinicians specializing in pelvic floor physiotherapy and sexual health, and one male and one female with SCI. We made minor adaptations based on their feedback. The University of British Columbia's Behavioral Research Ethics Board approved this study. We report survey findings according to the Checklist for Reporting Results of Online E-Surveys (CHERRIES) (30).

The purpose of this study was to explore knowledge, attitudes, and practices related to PFMT in the SCI population. Generally, people with SCI were aware of PFMT and had favorable attitudes toward it; however, few had actually practiced PFMT. Females were more knowledgeable and generally had stronger belief that they would benefit from PFMT compared to males. More people with miSCI than mcSCI reported that they felt they could benefit from PFMT and had actually participated in a PFMT program.

People with SCI appear to have greater awareness of PFMT when compared to the general population. Surveys of pregnant and post-partum women report awareness of PFMT in the range of 6–56%, compared to 63% of our respondents who indicated knowledge of this type of therapy (21–24). The extent of PFMT knowledge in people with SCI may not be surprising as, following their injury, they may be more aware of the urinary system and associated structures as they work with clinicians to develop individualized bladder management routines (31).

Despite the majority of respondents being aware of PFMT and having favorable attitudes toward this type of therapy, the prevalence of practicing PFMT appears to be low in this population. Most participants indicated that a healthcare worker had never discussed PFMT with them post-injury, which is not surprising given that there are limited studies to date exploring the benefits of PFMT for people with SCI (10–12). Indeed, in international clinical guidelines for treating neurogenic lower urinary tract dysfunction, the use of PFMT is either not included (32), or is mentioned briefly but without clear instruction on how to deliver such a program (33, 34). Confidence and experience in delivering a PFMT is crucial for clinicians to being able to implement these programs. This is demonstrated by a recent survey of obstetric health care workers who indicated that while they were knowledgeable about and had favorable attitudes toward PFMT, they had poor confidence in delivering and evaluating correct performance of PFMT treatment, resulting in fewer of their patients practicing PFMT (35). As our results indicate that people with SCI feel most comfortable discussing PFMT with a health care professional, future work should explore the extent to which practitioners managing the clinical care of people with SCI feel comfortable prescribing PFMT and providing resources on this therapy.

Of the respondents who reported experience previously participating in PFMT, program parameters varied widely, indicating inconsistent PFMT prescription. This is in line with systematic reviews that have found that PFMT programs lack consistency across research studies as well as in clinical practice (36, 37). While there is some evidence to support optimal training loads in able-bodied women with urinary incontinence (38), further research is needed to explore the optimal training parameters for PFMT programs in neurological populations such as those with SCI. However, despite variations in PFMT programs, the majority of respondents perceived that their program as being beneficial.

When compared to female respondents, males were more likely to be unsure about the purpose of PFMT, unsure of where to access PFMT, and less likely to think they could benefit from PFMT. As this therapy is most commonly prescribed to females for post-partum recovery (5), this may be the only context in which males are familiar with PFMT, consequently leading to the presumption that PFMT would not be beneficial to them. Indeed, in our survey, some male respondents specifically answered that they thought PFMT could only be performed by females. However, it is also possible that our survey could have been subject to a sampling bias which could have impacted our findings. If females are more likely to be knowledgeable or interested in PFMT, it is possible we unintentionally attracted more female than male participants by advertising that the survey was about “pelvic floor muscle training.” Indeed, our sample does not reflect the typical male:female distribution of the SCI population; more than two-thirds of our respondents were female, in contrast to the ~30% of the global SCI population being female (27, 28). However, if our higher female participation rates are indicative that females were more likely to engage in this survey topic, this would still support that males may be lacking knowledge on PFMT, suggesting there is need to create sex-specific strategies for education on this topic.

There were no significant differences between people with mcSCI and miSCI with respect to having heard about PFMT. More people with miSCI reported having practiced PFMT. As it is generally assumed that those diagnosed with mcSCI would have no voluntary control over their pelvic floor muscles, it is perhaps unsurprising that clinicians would be less likely to prescribe this type of therapy (14). However, increasing evidence supports that people classified with mcSCI have residual descending motor input to muscles below their injury level (13–17), including the pelvic floor muscles (18). Previous work has also demonstrated that it is possible to train the trunk musculature below the level of injury in people with mcSCI to improve seated balance (15, 17); it remains unclear if the pelvic floor muscles may be similarly trained for improvements in urogenital function. As our results suggest that people with mcSCI are interested in learning more about PFMT and think they could benefit from this type of training, future studies should explore the potential use of PFMT for people with this type of injury.

There are some limitations that should be considered when interpreting the results from this survey. Our online survey was susceptible to false responses as we had to rely on participant's self-screening relative to the eligibility criteria. While we attempted to eliminate these false responses, it is possible that some valid responses may have been erroneously excluded or invalid responses included. However, by using an internet-based survey we were able to reach a large and specific population in a timely and cost-effective manner. Further, respondents, who might have otherwise been hesitant to talk about health-related topics (such as PFMT) face-to-face, were able to participate anonymously (39). This survey did not inquire about respondents' current urogenital health or extent of neurogenic lower urinary tract dysfunction, so we could not evaluate the likelihood that respondents would be candidates for PFMT. However, considering that 80% of the SCI population is reported to experience bladder dysfunction (1), we could assume that a majority of respondents had some degree of neurogenic lower urinary tract symptoms. There may also be sampling bias within the survey in that almost all respondents were from Canada or the United States. Health care systems and the popularity of therapeutic approaches vary globally; the results from this study may only reflect the experiences and perspectives of individuals with SCI who are living in North America.

In conclusion, our results suggest that the majority of people with SCI would like to learn more about PFMT and believe they could benefit from this therapy, but only a small proportion of respondents had actually undertaken a PFMT program. As trained and knowledgeable staff are needed to improve access to PFMT for those with SCI, future studies should explore the KAP of clinicians who would be prescribing and supporting PFMT programs for people with SCI. Differences between males and females regarding baseline knowledge of the pelvic floor muscles and attitudes toward PFMT should be further explored in future studies of the implementation of this therapy in the SCI population.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by University of British Columbia Clinical Research Ethics Board. The patients/participants provided their written informed consent to participate in this study.

MS-K and AW made significant contributions to the study design, data collection, data analysis and interpretation, and drafting and revising this manuscript. WM and TL made significant contributions to developing the idea for the study, study design, interpreting the data, and revising the manuscript. All authors contributed to the article and approved the submitted version.

This project was funded by the Canadian Institutes of Health Research (PTJ-166040).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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