Multimodal pelvic floor rehabilitation in chronic stroke survivors: Long-term efficacy, optimal protocols, and adjunctive therapies for comprehensive pelvic floor dysfunction: A multicenter randomized controlled trial

Multimodal pelvic floor rehabilitation in chronic stroke survivors: Long-term efficacy, optimal protocols, and adjunctive therapies for comprehensive pelvic floor dysfunction: A multicenter randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Multimodal pelvic floor rehabilitation in chronic stroke survivors: Long-term efficacy, optimal protocols, and adjunctive therapies for comprehensive pelvic floor dysfunction: A multicenter randomized controlled trial Muslim Khan, Ayman Abdullah Alhammad, Mshari Alghadier, Saeed Mufleh Alnasser, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8765470/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Background Pelvic floor dysfunction (PFD), encompassing urinary incontinence, fecal incontinence/constipation, and sexual dysfunction, is a prevalent yet often overlooked complication in chronic stroke survivors profoundly impacting quality of life, social participation, and caregiver burden. Prior research has highlighted gaps in long-term outcome data, optimal dosing protocols, adjunctive therapies (biofeedback and neuromuscular electrical stimulation [NMES]), and comprehensive coverage of bowel and sexual domains. Objective This multicenter randomized controlled trial aimed to evaluate the long-term efficacy of multimodal pelvic floor muscle training (PFMT), optimize intervention protocols, assess adjunctive biofeedback and NMES, develop domain-specific approaches for bowel and female sexual dysfunction, examine partner impacts, integrate standardized assessments, correlate improvements with quality-of-life outcomes, and identify prognostic factors. Methods Four hundred twenty chronic stroke survivors with PFD were randomized into four groups: standard PFMT, intensified PFMT, PFMT + biofeedback, or PFMT + NMES. Interventions lasted 16 weeks (supervised), followed by self-managed home maintenance with monthly coaching up to 12 months. Primary outcomes included pelvic floor muscle strength (Modified Oxford scale and perineometry), urinary symptoms (ICIQ-UI SF), and bowel symptoms (Wexner score). Secondary outcomes encompassed sexual function (FSFI/IIEF-5),partner satisfaction, quality of life (SF-36, SIS), and adherence. Results At 12 months, 84% of participants sustained ≥ 80% of gains achieved at 16 weeks. All groups showed significant improvements in muscle strength and urinary symptoms, with convergence across groups long-term. PFMT + NMES demonstrated superiority in bowel outcomes (greater Wexner score reduction and remission rates; p = 0.002), while PFMT + biofeedback excelled in female sexual function (notably lubrication and arousal; p < 0.01). Perineometry exhibited higher reliability than digital palpation. Objective gains correlated moderately with enhanced quality of life, emotional well-being, and social participation. Poorer responders were predicted by hemorrhagic stroke, severe disability, and left-sided lesions. Conclusion Multimodal PFMT yields durable, domain-specific benefits in chronic stroke-related PFD, with NMES and biofeedback providing targeted advantages for bowel and female sexual recovery, respectively. Routine PFD screening and multimodal interventions should be incorporated into stroke rehabilitation guidelines. Clinical Implications: Implementing standardized PFD screening and multimodal PFMT during sub-acute stroke phases could significantly reduce long-term health issues, lessen caregiver burden, and improve interpersonal relationships. Trial registration : ClinicalTrials.govNCT06234567,retrospectively registered on 29 th December,2025 stroke pelvic floor dysfunction pelvic floor muscle training biofeedback neuromuscular electrical stimulation urinary incontinence bowel dysfunction sexual dysfunction long-term outcomes quality of life Full Text Additional Declarations No competing interests reported. the author has responded: "Kindly receive the link to the de-identified data set for this study; https://doi.org/10.6084/m9.figshare.30983716" Supplementary Files CONSORTChecklist.pdf TrialProtocol.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 03 Feb, 2026 Submission checks completed at journal 03 Feb, 2026 First submitted to journal 03 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8765470","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":585421274,"identity":"da1be5d5-0b1e-4c67-a4fd-29bc531d1780","order_by":0,"name":"Muslim Khan","email":"","orcid":"","institution":"Iqra National University","correspondingAuthor":false,"prefix":"","firstName":"Muslim","middleName":"","lastName":"Khan","suffix":""},{"id":585421275,"identity":"6cf93016-ba70-4cb3-82c0-3adcaf4b0011","order_by":1,"name":"Ayman Abdullah Alhammad","email":"","orcid":"","institution":"Taibah University","correspondingAuthor":false,"prefix":"","firstName":"Ayman","middleName":"Abdullah","lastName":"Alhammad","suffix":""},{"id":585421276,"identity":"4f5f401d-0773-448d-82cc-a062a4c447da","order_by":2,"name":"Mshari Alghadier","email":"","orcid":"","institution":"Prince Sattam bin Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"Mshari","middleName":"","lastName":"Alghadier","suffix":""},{"id":585421277,"identity":"7fdc0c94-6b21-40e7-9c7d-e4cfa0970903","order_by":3,"name":"Saeed Mufleh Alnasser","email":"","orcid":"","institution":"Armed Forces Hospital, Southern Region","correspondingAuthor":false,"prefix":"","firstName":"Saeed","middleName":"Mufleh","lastName":"Alnasser","suffix":""},{"id":585421278,"identity":"f4f27516-c675-4029-9add-e0ac13c991c2","order_by":4,"name":"Abdullah Basheer Alanazi","email":"","orcid":"","institution":"Medina Health Cluster","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"Basheer","lastName":"Alanazi","suffix":""},{"id":585421279,"identity":"8117531e-5c65-47a0-8023-22dbdf79ab88","order_by":5,"name":"Hasan Ali Abdullah AlAidarous","email":"","orcid":"","institution":"Albaha University","correspondingAuthor":false,"prefix":"","firstName":"Hasan","middleName":"Ali Abdullah","lastName":"AlAidarous","suffix":""},{"id":585421280,"identity":"64da2252-bce3-4f57-ab74-4cf4a59bbf23","order_by":6,"name":"Engy BadrEldin Saleh Moustafa","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Engy","middleName":"BadrEldin Saleh","lastName":"Moustafa","suffix":""},{"id":585421283,"identity":"e5b70d45-dbe5-415d-932c-d1b38be3f47b","order_by":7,"name":"Ahmed Ibrahim Al Kharusi","email":"","orcid":"","institution":"University of Nizwa","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Ibrahim Al","lastName":"Kharusi","suffix":""},{"id":585421284,"identity":"2d7265c0-b71c-408a-a5cb-c8dbb2b7ebea","order_by":8,"name":"Hassan Abdelnour","email":"","orcid":"","institution":"Jerash University","correspondingAuthor":false,"prefix":"","firstName":"Hassan","middleName":"","lastName":"Abdelnour","suffix":""},{"id":585421290,"identity":"e503ecd2-df3d-446b-9178-b6824a10a54b","order_by":9,"name":"Edward Muteesasira","email":"data:image/png;base64,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","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Edward","middleName":"","lastName":"Muteesasira","suffix":""}],"badges":[],"createdAt":"2026-02-02 13:23:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8765470/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8765470/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102404090,"identity":"b3ebf5f1-42c9-4574-9325-afbfbd3d4d81","added_by":"auto","created_at":"2026-02-11 10:59:32","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":965846,"visible":true,"origin":"","legend":"","description":"","filename":"FinalManuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8765470/v1_covered_3f5ea783-fa4c-4692-ac72-7f416868808c.pdf"},{"id":101948418,"identity":"0b4118ba-0294-4d52-9400-fa7eaae11a7e","added_by":"auto","created_at":"2026-02-05 10:13:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":147787,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORTChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8765470/v1/702f71bc9b7c1f4b7f4c462d.pdf"},{"id":101948391,"identity":"e509e12b-4e0b-4a7a-8146-90a6e74162fb","added_by":"auto","created_at":"2026-02-05 10:13:09","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":268605,"visible":true,"origin":"","legend":"","description":"","filename":"TrialProtocol.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8765470/v1/825ecfabe17841300348801e.pdf"}],"financialInterests":"\u003cp\u003eNo competing interests reported.\u003c/p\u003e\n\u003cp\u003ethe author has responded: \"Kindly receive the link to the de-identified data set for this study; https://doi.org/10.6084/m9.figshare.30983716\"\u003c/p\u003e","formattedTitle":"Multimodal pelvic floor rehabilitation in chronic stroke survivors: Long-term efficacy, optimal protocols, and adjunctive therapies for comprehensive pelvic floor dysfunction: A multicenter randomized controlled trial","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"stroke, pelvic floor dysfunction, pelvic floor muscle training, biofeedback, neuromuscular electrical stimulation, urinary incontinence, bowel dysfunction, sexual dysfunction, long-term outcomes, quality of life","lastPublishedDoi":"10.21203/rs.3.rs-8765470/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8765470/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePelvic floor dysfunction (PFD), encompassing urinary incontinence, fecal incontinence/constipation, and sexual dysfunction, is a prevalent yet often overlooked complication in chronic stroke survivors profoundly impacting quality of life, social participation, and caregiver burden. Prior research has highlighted gaps in long-term outcome data, optimal dosing protocols, adjunctive therapies (biofeedback and neuromuscular electrical stimulation [NMES]), and comprehensive coverage of bowel and sexual domains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis multicenter randomized controlled trial aimed to evaluate the long-term efficacy of multimodal pelvic floor muscle training (PFMT), optimize intervention protocols, assess adjunctive biofeedback and NMES, develop domain-specific approaches for bowel and female sexual dysfunction, examine partner impacts, integrate standardized assessments, correlate improvements with quality-of-life outcomes, and identify prognostic factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour hundred twenty chronic stroke survivors with PFD were randomized into four groups: standard PFMT, intensified PFMT, PFMT + biofeedback, or PFMT + NMES. Interventions lasted 16 weeks (supervised), followed by self-managed home maintenance with monthly coaching up to 12 months. Primary outcomes included pelvic floor muscle strength (Modified Oxford scale and perineometry), urinary symptoms (ICIQ-UI SF), and bowel symptoms (Wexner score). Secondary outcomes encompassed sexual function (FSFI/IIEF-5),partner satisfaction, quality of life (SF-36, SIS), and adherence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt 12 months, 84% of participants sustained ≥ 80% of gains achieved at 16 weeks. All groups showed significant improvements in muscle strength and urinary symptoms, with convergence across groups long-term. PFMT + NMES demonstrated superiority in bowel outcomes (greater Wexner score reduction and remission rates; p = 0.002), while PFMT + biofeedback excelled in female sexual function (notably lubrication and arousal; p \u0026lt; 0.01). Perineometry exhibited higher reliability than digital palpation. Objective gains correlated moderately with enhanced quality of life, emotional well-being, and social participation. Poorer responders were predicted by hemorrhagic stroke, severe disability, and left-sided lesions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMultimodal PFMT yields durable, domain-specific benefits in chronic stroke-related PFD, with NMES and biofeedback providing targeted advantages for bowel and female sexual recovery, respectively. Routine PFD screening and multimodal interventions should be incorporated into stroke rehabilitation guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Implications:\u003c/strong\u003e Implementing standardized PFD screening and multimodal PFMT during sub-acute stroke phases could significantly reduce long-term health issues, lessen caregiver burden, and improve interpersonal relationships.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e: ClinicalTrials.govNCT06234567,retrospectively registered on 29\u003csup\u003eth\u003c/sup\u003e December,2025\u003c/p\u003e","manuscriptTitle":"Multimodal pelvic floor rehabilitation in chronic stroke survivors: Long-term efficacy, optimal protocols, and adjunctive therapies for comprehensive pelvic floor dysfunction: A multicenter randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-05 10:11:51","doi":"10.21203/rs.3.rs-8765470/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-04T04:59:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T19:12:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2026-02-03T19:02:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab109e1a-aeed-4a51-bf2c-950e17dff693","owner":[],"postedDate":"February 5th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-10T11:38:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-05 10:11:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8765470","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8765470","identity":"rs-8765470","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}