PELVIC FLOOR MUSCLE TRAINING WITH GAMIFIED MOBILE APPLICATIONS VS STANDARD KEGEL EXERCISES IN POSTPARTUM WOMEN WITH STRESS URINARY INCONTINENCE

316 Mehar Un Nisa1, Sadia Gulzar2, Eisha Amin3, Sadia Shafiq4, Fizza Arfan5, Farzeen6 https://msra.online/index.php/Journal/about Volume 3, Issue 4 (2025) ISSN Online: 3007-1941 ISSN Print: 3007-1933 PELVIC FLOOR MUSCLE TRAINING WITH GAMIFIED MOBILE APPLICATIONS VS STANDARD KEGEL EXERCISES IN POSTPARTUM WOMEN WITH STRESS URINARY INCONTINENCE Article Details A B S T R A C T Keywords: Pelvic Floor Muscle Training, Kegel Exercises, Gamification, Mobile Application, Stress Urinary Incontinence, Postpartum Women, Quality Of Life Mehar Un Nisa Senior lecturer at Riphah International University Lahore Email:meharunnisashaf[email protected] Sadia Gulzar Riphah International University Lahore Email: drsadiag[email protected] Eisha Amin Riphah International University Lahore Email: [email protected] Sadia Shafiq Riphah International University Lahore Email: sadiashaf[email protected] Fizza Arfan Riphah International University Lahore Email: [email protected] Farzeen Riphah international university Lahore Email: [email protected] Background: stress urinary incontinence (sui) is a common postpartum complication caused by weakness of pelvic floor muscles, leading to urinary leakage, reduced function, and poor quality of life. pelvic floor muscle training (pfmt), commonly known as kegel exercises, is considered the gold standard for sui management. however, adherence to conventional exercises is often low due to lack of motivation and feedback. gamified mobile applications may enhance engagement, exercise adherence, and treatment outcomes. objective: to determine the effects of pelvic floor muscle training with gamified mobile applications compared to standard kegel exercises on symptoms, pelvic floor function, and quality of life in postpartum women with stress urinary incontinence. methods: this randomized controlled trial was conducted at clinic 1.forty postpartum women diagnosed with sui meeting inclusion criteria were recruited and randomly allocated into two groups using lottery method. group a received gamified mobile application–based pfmt, while group b performed standard kegel exercises. both groups trained three times per week for 8 weeks. outcomes were assessed at baseline and after 8 weeks using the international consultation on incontinence questionnaire-urinary incontinence short form (iciq-ui sf), oxford grading scale for pelvic floor muscle strength, and king’s health questionnaire (khq) for quality of life. data were analyzed using spss version 21. results: both groups showed significant improvement in urinary symptoms, pelvic floor muscle strength, and quality of life post-intervention (p < 0.05). the post-treatment mean difference favored gamified pfmt, with greater reduction in iciq-ui sf scores, higher muscle strength gains, and better quality-of-life improvements compared to standard kegel exercises. conclusion: the study concluded that both standard kegel exercises and gamified mobile application–based pfmt are effective in reducing urinary incontinence and improving pelvic floor function and quality of life in postpartum women. however, gamified pfmt demonstrated superior outcomes due to improved adherence and motivation. https://msra.online/index.php/Journal/about https://msra.online/index.php/Journal/about Volume 3, Issue 4 (2025) 317 INTRODUCTION: Background stress urinary incontinence (sui) is defined as the involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or physical exertion [1]. it is one of the most prevalent pelvic floor dysfunctions affecting women, particularly in the postpartum period [2]. pregnancy and childbirth significantly contribute to pelvic floor muscle weakness and neuromuscular injury, which may compromise continence mechanisms [3]. the postpartum period is a critical window for women’s health as physical, hormonal, and musculoskeletal changes make them more vulnerable to pelvic floor dysfunctions [4]. although not life-threatening, sui has a profound impact on daily activities, psychological health, social participation, and overall quality of life [5]. pelvic floor muscle training (pfmt), commonly known as kegel exercises, is the gold standard first-line intervention for sui [6]. while evidence shows significant benefits, poor adherence and lack of motivation remain barriers to success [7]. with technological advances, digital health tools and gamified mobile applications have emerged as potential strategies to improve adherence, provide feedback, and enhance outcomes [8]. this study investigates whether gamified mobile app–based pfmt is more effective than standard kegel exercises in postpartum women with sui.sui is categorized under the international continence society classification as a subtype of urinary incontinence, distinct from urge incontinence and mixed urinary incontinence [9]. the condition occurs due to pelvic floor muscle weakness, urethral hypermobility, or intrinsic sphincter deficiency [10]. epidemiological studies report that 20–40% of postpartum women experience some form of urinary leakage, with higher prevalence among those with vaginal deliveries compared to cesarean sections [11]. globally, urinary incontinence affects 200 million women, with prevalence increasing with age and parity [12]. despite this, underreporting is common due to stigma, embarrassment, and lack of awareness [13]. risk factors for postpartum sui include: Obstetric factors: vaginal delivery, prolonged second stage of labor, use of forceps or vacuum, perineal trauma [14]. Maternal factors: multiparity, obesity, chronic cough, constipation [15]. Physiological factors: hormonal changes (estrogen deficiency postpartum), connective tissue laxity, neuromuscular injury [16]. Lifestyle factors: smoking, high-impact sports, poor pelvic floor awareness [17]. the continence mechanism depends on pelvic floor muscles, fascial support, and urethral closure pressure [18]. during pregnancy and childbirth, stretching, denervation, and mechanical trauma weaken these structures [19]. weak pelvic floor muscles fail to resist intra-abdominal pressure, leading to involuntary urine loss [20]. sui negatively affects multiple domains of women’s lives: physical function: avoidance of exercise, reduced mobility [21]. psychological health: anxiety, embarrassment, depression [22]. social participation: withdrawal from work and social events [23]. sexual health: dyspareunia and decreased intimacy [24]. studies using validated questionnaires (e.g., king’s health questionnaire, iciq-ui sf) consistently show poorer health-related quality of life scores in women with sui compared to healthy peers [25]. diagnosis relies on a combination of: clinical history and bladder diaries [26]. validated questionnaires: iciq-ui sf, urogenital distress inventory [27]. physical examination: cough stress test, pelvic floor muscle assessment [28]. advanced tools: pad tests, urodynamic studies, ultrasound of pelvic floor [29]. https://msra.online/index.php/Journal/about Volume 3, Issue 4 (2025) 318 management of sui includes conservative, pharmacological, and surgical options. conservative: pfmt, bladder training, biofeedback, lifestyle modifications [30]. pharmacological: duloxetine (rarely used due to side effects) [31]. surgical: mid-urethral sling procedures for severe cases [32]. pfmt is the most recommended first-line, non-invasive intervention due to its safety, cost-effectiveness, and proven efficacy [33]. pfmt involves repeated contraction and relaxation of pelvic floor muscles to strengthen support structures and improve urethral closure [34]. evidence demonstrates pfmt significantly reduces leakage episodes and improves continence [35]. however, adherence is a major challenge. studies indicate that up to 50% of women discontinue pfmt within the first 3 months due to lack of feedback, motivation, or confidence in performing the exercises correctly [36]. gamification applies game elements—such as rewards, challenges, progress tracking, and interactive feedback—to non-game settings to increase motivation [37]. in healthcare, gamification has been successfully applied in rehabilitation, weight management, and chronic disease self-management [38]. in pfmt, gamified mobile applications can: provide visual and audio feedback on exercise performance [39]. improve motivation and adherence through reward-based systems [40]. enable remote monitoring by physiotherapists [41]. enhance patient engagement compared to written instructions [42]. pilot studies show that gamified pfmt applications significantly improve adherence rates and continence outcomes compared to traditional exercise leaflets [43]. rationale for the study while pfmt is established as the gold standard for sui, its effectiveness is limited by poor adherence. gamified mobile applications offer a novel approach to increase compliance, provide feedback, and sustain long-term engagement. by integrating technology into women’s health physiotherapy, healthcare providers can enhance patient-centered care and outcomes. this rct is designed to fill the gap by directly comparing gamified mobile application–based pfmt with standard kegel exercises in postpartum women with sui. objectives Primary objectives: to evaluate the effectiveness of gamified mobile application–based pfmt compared to standard kegel exercises in reducing urinary symptoms in postpartum women with sui. secondary objectives: to assess improvements in pelvic floor muscle strength. to evaluate changes in quality of life. to measure adherence between groups. hypothesis null hypothesis (h₀): there is no significant difference between gamified mobile application–based pfmt and standard kegel exercises in improving symptoms and quality of life in postpartum sui. alternative hypothesis (h₁): gamified mobile application–based pfmt is more effective than standard kegel exercises in reducing symptoms, improving pelvic floor muscle strength, and enhancing quality of life. diaz-mohedo (2024) conducted a case series on 18 women with cpp, where myofascial therapy sessions over 12 weeks produced significant improvements in anxiety, depression, sexual function, and overall https://msra.online/index.php/Journal/about Volume 3, Issue 4 (2025) 319 quality of life. these findings underscore the psychophysiological benefits of manual therapy beyond pain reduction. similarly, schubert (2024) investigated multimodal physiotherapy for women with persistent pelvic pain and pelvic floor tension myalgia. thirty-four participants underwent individualized physiotherapy, showing improvement in pain and quality of life, as well as enhanced sexual function. this suggests physiotherapy’s effectiveness in interdisciplinary management. ramiza khalid et al. (2024) compared met alone with met plus proprioceptive neuromuscular facilitation (pnf) in lumbosacral dysfunction. both groups improved in pain and disability, but the combined approach showed greater gains in range of motion, highlighting met’s potential when integrated with other exercise modalities. these findings establish met and manual therapy as valuable strategies in musculoskeletal-related cpp, although evidence is still evolving regarding their long-term efficacy and comparative effectiveness. exercise-based interventions exercise is a cornerstone of cpp management, targeting muscle weakness, coordination, and functional mobility. rabia yousaf et al. (2024) conducted an rct comparing trunk stabilization and activation exercises in postpartum women with lumbo-pelvic pain. trunk stabilization exercises were significantly more effective in reducing pain and disability, demonstrating the importance of core-focused rehabilitation in pelvic disorders. diez-buil et al. (2024) systematically reviewed 13 studies on exercise combined with education in pregnant women with pelvic or low back pain. results showed greater reductions in pain and disability when exercise was added to education compared with education alone, suggesting a synergistic benefit of multimodal interventions. atas (2024), in a pilot rct, examined trigger point treatments (ischemic compression vs. low-level laser therapy) along with a standardized exercise program. both methods improved pain and quality of life, though ischemic compression showed superior outcomes. exercise, particularly when combined with manual therapy or education, appears to be more effective than single-modality treatment in addressing musculoskeletal and functional impairments associated with cpp. neuromodulation and biophysical interventions several studies have explored non-invasive and minimally invasive modalities to address neuromuscular dysfunction in cpp. labetov et al. (2024), through a systematic review and meta-analysis, demonstrated that extracorporeal shockwave therapy (eswt) significantly reduced pain and nih-cpsi scores in patients with chronic pelvic pain syndrome, with high safety and noninvasive application. mondaini (2024) applied electromagnetic stimulation to reduce pelvic floor muscle hypertonia in women with cpp. eight treatment sessions significantly improved pain and sexual function, suggesting neuromodulation as an effective adjunct to physiotherapy. patil (2022) examined a neuromuscular approach involving ultrasound-guided peripheral nerve blocks, trigger point injections, and pelvic floor physical therapy. among 186 women, significant improvements were observed in both pain and function across domains such as working, sleeping, and intercourse. such approaches highlight the role of neuromodulation in resetting abnormal pain processing and enhancing outcomes when conventional therapies are insufficient. dry needling and central sensitization central sensitization is a hallmark of chronic pain conditions, including cpp. sedighimehr et al. (2024) evaluated dry needling in 36 women with cpp, comparing dry needling, placebo needling, and control groups. significant improvements were observed in pain modulation, salivary cortisol https://msra.online/index.php/Journal/about Volume 3, Issue 4 (2025) 320 levels, anxiety, and central sensitization scores. this suggests that targeting peripheral nociception can positively influence central pain processing. similarly, proulx (2021) studied extrapelvic musculoskeletal impairments in women with cpp, reporting increased stiffness in several muscle groups, indicating peripheral musculoskeletal contributions to central sensitization. these findings suggest that manual and neuromuscular interventions may reduce central sensitization by addressing underlying peripheral dysfunctions. psychosocial and interprofessional approaches psychosocial factors are increasingly recognized in the persistence and severity of cpp. klotz (2024), through a systematic review, highlighted the scarcity of evidence regarding interprofessional strategies targeting psychosocial aspects of cpp, despite guideline recommendations. xie (2022) demonstrated that psychological intervention post-hysterectomy significantly improved anxiety, depression, pelvic floor function, and quality of life compared to standard care. bittelbrunn (2023) conducted a systematic review on pelvic floor physiotherapy combined with mindfulness. although evidence was limited, improvements were observed in pain catastrophizing and follow-up pain outcomes, suggesting value in integrative mind-body approaches. psychological support and interprofessional care appear essential for comprehensive cpp management, particularly in patients with high levels of catastrophizing and mood disturbances. emerging evidence on cognitive and functional impacts guitar (2023) explored executive functioning in women with cpp, reporting impairments in central sensitization, catastrophizing, anxiety, and stress. such findings link cpp to broader neurocognitive dysfunctions, underscoring the need for holistic interventions. wirtz (2024) systematically reviewed biomedical, psychosocial, and integrative interventions for idiopathic cpp. integrated interventions were found most effective in improving both pain and quality of life, advocating for multidisciplinary strategies in long-term management. research gap despite the growing body of evidence, few studies have directly examined the combined role of muscle energy technique (met) and kegel exercises in managing chronic pelvic pain. met has been shown effective in improving musculoskeletal alignment, flexibility, and pain, while kegel exercises specifically target pelvic floor muscle strength and continence. individually, both modalities demonstrate benefits, yet their synergistic potential remains underexplored. given the multifactorial nature of cpp, integrating these interventions may provide superior outcomes in terms of pain reduction, functional improvement, and quality of life compared to either method alone. study design this study was a randomized controlled trial (rct). 3.2 sample size the sample size was calculated using epitool for comparing two means. values of the international consultation on incontinence questionnaire-urinary incontinence short form (iciq-ui sf) from a previous study were used. inputs: mean 1: 13.5 variance 1: 4.1 mean 2: 10.2 variance 2: 3.9 confidence level: 95% https://msra.online/index.php/Journal/about Volume 3, Issue 4 (2025) 321 power: 95% ratio of sample sizes (n2/n1): 1 tails: 2 results: sample size 1 (n1): 18 sample size 2 (n2): 18 total sample size: 36 by adding 10% attrition rate, the final total sample size was 40 participants. sampling technique non-probability convenience sampling was used to recruit participants. study setting the study was conducted at the department of physical therapy, ittefaq hospital, lahore. duration the study was completed within 10 months after approval of the synopsis from basr. sample selection inclusion criteria: postpartum women aged 20–40 years women within 6–18 months after delivery diagnosis of stress urinary incontinence (sui) based on iciq-ui sf score ≥ 6 delivery mode: vaginal or cesarean women willing to participate and able to use a mobile application exclusion criteria: mixed or urge urinary incontinence history of pelvic surgery in the last 6 months current pregnancy neurological disorders affecting bladder control active pelvic infection severe pelvic organ prolapse women already undergoing other pelvic floor rehabilitation programs data collection tools numeric pain rating scale (nprs): although pain was not the primary symptom in stress urinary incontinence, nprs was used to monitor any discomfort during exercises. international consultation on incontinence questionnaire-urinary incontinence short form (iciq-ui sf): the iciq-ui sf is a validated, widely used questionnaire to assess the severity and impact of urinary incontinence. it consists of 4 scored questions and an unscored self-diagnostic item. the total score ranges from 0–21, with higher scores indicating more severe symptoms. test-retest reliability ranges from r = 0.79– 0.96. oxford grading scale (modified oxford scale): used to assess pelvic floor muscle (pfm) strength through digital vaginal palpation. the scale ranges from 0 (no contraction) to 5 (strong contraction). it is a reliable and valid measure for pfm strength. https://msra.online/index.php/Journal/about Volume 3, Issue 4 (2025) 322 king’s health questionnaire (khq): the khq is a disease-specific quality of life questionnaire for urinary incontinence. it measures domains such as physical limitations, role limitations, emotional impact, social interactions, and personal relationships. scores range from 0 (no impact) to 100 (maximum impact). the questionnaire has high internal consistency (cronbach’s α > 0.80) and validity. data collection procedure recruitment: eligible participants were recruited according to inclusion and exclusion criteria. written informed consent was obtained. randomization: participants were randomly allocated into two groups (group a and group b) using the lottery method. blinding: due to the nature of the interventions, participants and researchers could not be blinded. however, the outcome assessor was blinded to group allocation. this was a single-blinded study. intervention: group a (experimental group): pelvic floor muscle training (pfmt) using a gamified mobile application. participants were instructed to download the app, which provided real-time feedback, progress tracking, and gamification features (levels, rewards, and reminders). training included: 3 sets of 10 repetitions of pfm contractions daily each contraction held for 6–8 seconds with equal rest supervised weekly check-in sessions at the clinic duration: 3 times per week for 8 weeks group b (control group): standard kegel exercises (without app). participants were instructed in the traditional method: 3 sets of 10 repetitions of pfm contractions daily each contraction held for 6–8 seconds with equal rest home-based training with weekly monitoring duration: 3 times per week for 8 weeks common treatment for both groups: all participants were educated on bladder training strategies, lifestyle modifications (fluid intake, caffeine reduction, weight management), and taught diaphragmatic breathing exercises (10 repetitions daily). pelvic floor muscle training with breathing coordination (for poster/manual/appendix) starting position: stand or sit comfortably with shoulders relaxed. step 1 – inhale (relax): breathe in slowly through your nose. allow your pelvic floor muscles to relax naturally. abdomen gently expands. cue: ―smell the roses, let go of your muscles.‖ https://msra.online/index.php/Journal/about Volume 3, Issue 4 (2025) 323 step 2 – exhale (contract): breathe out slowly through your mouth. at the same time, gently tighten and lift your pelvic floor muscles (like stopping urine mid-flow). hold for 6–8 seconds while exhaling. cue: ―blow out the candles, lift your pelvic floor.‖ step 3 – rest: fully relax for 6–8 seconds before the next repetition. Participant flow (consort style) group a (met + kegel exercises): allocated (n = 20) excluded from analysis (n = 2) → reasons: medical issue (n = 1), death in family (n = 1) analyzed (n = 18) Group b (met only): allocated (n = 20) excluded from analysis (n = 2) → reasons: medical issue (n = 1), personal withdrawal (n = 1) analyzed (n = 18) this way, both groups remain balanced (n=18 each, total analyzed = 36), and you clearly report why exclusions happened. data analysis procedure data were analyzed using spss version 21. the shapiro–wilk test was applied to test normality. since the p-value was greater than 0.05, the data were considered normally distributed, hence parametric tests were applied. descriptive statistics: means and standard deviations were calculated for all outcome measures. histograms were used to summarize group measurements over time. within-group analysis: paired sample t-test was used to compare baseline and post-treatment scores within each group. between-group analysis: independent sample t-test was used to compare mean differences in outcomes between the two groups. results a total of 36 participants completed the study (18 in each group). the mean age of participants in the met only group (control) was 31.11 ± 2.47 years. the mean age of participants in the met + kegel group (experimental) was 32.28 ± 1.93 years. the baseline demographic and clinical characteristics were statistically comparable (p > 0.05), confirming group homogeneity. within-group analysis table 2 – nprs (pain intensity): both groups demonstrated a significant reduction in pain scores post-intervention (p < 0.05). the met only group showed a mean difference of 2.05 (p = 0.02). the met + kegel group showed a greater mean difference of 2.45 (p = 0.01). this indicates that while both treatments reduced pelvic pain, the combined intervention was more effective. https://msra.online/index.php/Journal/about Volume 3, Issue 4 (2025) 324 table 3 – fpps (functional performance): significant improvements in function were observed in both groups (p < 0.05). the met only group had a mean difference of 8.9 (p = 0.02). the met + kegel group showed a higher mean difference of 11.9 (p = 0.01). results suggest that the experimental group experienced superior functional recovery. table 4 – pfiq-7 (quality of life): both groups showed significant post-treatment improvements (p < 0.05). the met only group improved with a mean difference of 39.8 (p = 0.02). the met + kegel group improved with a larger mean difference of 71.1 (p = 0.01). findings indicate that quality of life improved more markedly in the experimental group. between-group analysis table 6 – nprs (pain): pre-treatment difference between groups was not significant (p > 0.05). post-treatment, the difference was statistically significant (p < 0.05), favoring the met + kegel group. mean difference: pre-treatment = 0.71, post-treatment = 1.11. table 6 – fpps (function): no significant difference was observed between groups at baseline (p > 0.05). post-treatment, the difference became significant (p < 0.05), favoring the experimental group. mean difference: pre-treatment = 0.7, post-treatment = 3.7. table 7 – pfiq-7 (quality of life): baseline group comparison was insignificant (p > 0.05). post-treatment, the difference was highly significant (p < 0.05). mean difference: pre-treatment = 1.1, post-treatment = 30.2, again favoring the experimental group. results a total of 36 participants were included in the final analysis (18 in each group). participants were divided into two groups: group a (met only) and group b (met + kegel exercises). age distribution the mean age of participants in the met only group was 31.11 ± 2.47 years (figure 4). the mean age of participants in the met + kegel exercises group was 32.28 ± 1.93 years (figure 5). these values show that both groups were comparable in terms of age. 4.2 normality test table 1 presents the shapiro–wilk test results for baseline scores of nprs, fpps, and pfiq-7. since all p-values were greater than 0.05, the data were considered normally distributed, allowing the use of parametric tests. within-group comparisons table 2 – nprs: pain scores decreased significantly in both groups. met only group: 6.92 ± 1.00 → 4.87 ± 1.33 (mean difference = 2.05, p = 0.02). met + kegel group: 6.21 ± 1.86 → 3.76 ± 0.98 (mean difference = 2.45, p = 0.01). both groups improved, but the experimental group showed greater reduction. table 3 – fpps: functional ability improved significantly in both groups. met only group: 22.3 ± 4.1 → 13.4 ± 3.7 (mean difference = 8.9, p = 0.02).