This study aimed to highlight the attitudes and barriers related to scientific research abilities and the knowledge about the clinical expertise of Brazilian physiotherapists that work in Women’s Health area, especially those involved in the management of pregnant and postpartum patients in Brazil, more specifically related to the prescription of the PFMT. Our results indicated that professionals are confident about their knowledge to search for answers in scientific databases when doubts arise from clinical practice and highlight that they search for information in different databases. The results also indicated that physiotherapists face important barriers that could impact the EBP’s implementation. Moreover, professionals seem to be aware of the available evidence supporting the effects of the PFMT in order to prevent and treat UI in the late pregnancy, however, there is a misunderstanding about the physiotherapists’ knowledge and scientific evidence about PFMT to prevent and treat UI and FI in the late postpartum. To the best of the authors’ knowledge, this is the first study to report the attitudes regarding two aspects of EBP of Brazilian physiotherapists that assist pregnant women. We found previous studies conducted with physiotherapists from Brazil regarding EBP [12, 13], however, the authors analyzed the data of professionals who worked in different fields of physiotherapy, not only in the Women’s Health area, which includes urogynecology, coloproctology, gynecology, obstetrics, female sexual dysfunctions, and mastology [20].
Physiotherapists included in the present study are confident about their ability to assess scientific evidence and to search for answers to the questions in clinical practice. This familiarity with EBP is considered an important factor that stimulates the progress of critical thinking and safety during the clinical practice of health professionals [21]. Another highlight from the present study is that most professionals searched for evidence in specific scientific databases. This result could be related to the free access to some databases (i.e., SciELO and Cochrane) provided in the Brazilian territory, such the SciELO, a digital library with scientific journals in Portuguese, Spanish, and English [22]. Many Brazilian professionals use it, including those who have difficulties with the English language as for presentisome of the original periodicals are written in Portuguese. However, as already pointed out in previous studies, a reasonable understating of the English-language and reading skills is necessary [23], as most of the evidence published in the other databases is in English nowadays.
Although it is known that EBP is an important criterion for decision-making in clinical practice, some barriers limit its implementation, such as those pointed out in the present study. Except for the limitation of understanding languages other than Brazilian Portuguese, the barriers reported by the physiotherapists were associated with scientific research issues, mainly understanding statistical analysis. One possible justification for this result may be the low percentage of participants who reported continuing education in the research area (i.e., master's and doctoral degrees). Moreover, the literature already reported that the lack of research skills is an important barrier to applying EBP [24]. Therefore, understanding the needs of physiotherapists may be necessary before while adopting the EBP process [25], which requires collaboration between councils and physiotherapists to minimize the impact of the main barriers identified by professionals.
In the present study, physiotherapists' attitudes regarding the assessment of PFM and PFM dysfunctions in pregnant and postpartum women were consistent with what has been reported in the literature [4] and guidelines [18]. Among the available methods for evaluating PFM, the most recommended by the International Continence Society are vaginal palpation and the manometer [21]. These two well-correlated methods are considered easy to apply [26] and in the present study, vaginal palpation was the prevalent method used during the evaluations. One of the main reasons may be related to the versatility of the method, as it can be applied by inserting one (unidigital) or two (bidigital) fingers [26]. In addition, it is a test that does not require any device to be done [27]. Despite that, the physical therapists hardly mentioned visual inspection, an essential evaluation during the PFM assessment [28]. This fact indicates that the assessment of the condition of the vulva and pelvic region may be neglected, compromising the search for signs that indicate the presence of some PFM dysfunction and, consequently, the prescription of adequate treatment.
Our results also showed that the voiding diary was the most used questionnaire during the assessment of pregnant women, followed by the International Consultation on Incontinence Questionnaire-Short form (ICIQ-SF), Female Sexual Function Index (FSFI), and King’s Health Questionnaire (KHQ). Although there is no standardized and validated voiding diary [28], the literature recommends using this instrument to evaluate patients [29]. In addition, it is known that using validated questionnaires and physical exams are essential to identify symptoms and to assess the patients’ response to treatment [30]. However, a few percentages of professionals seem to use scales as the global perceived effect (GPE) to evaluate the changes perceived by the patients after an intervention [31], results that could represent a lack of evaluation of one of the domains of the EBP: patients’ perception. In addition, approximately 20% of the professionals included in the present study do not apply any questionnaire in their clinical practice.
These results should concern health professionals, as it seems that only few are assessing an important outcome in clinical practice, which does not contribute to the EBP. In addition, it is already point out that questionnaires allow professionals to objectively measure symptoms and treatment results through patient-reported outcomes (PROMs) [32]. Therefore, our results highlight the need of a clear guidance to the Brazilian physiotherapists that work in the Women’s Health area, as their report seems not to consider the patients’ perception of a specific and important prescription, that is the PFMT during pregnancy.
Investigating physiotherapists’ knowledge about PFMT prescription is important to understand the context in which PFMT is being implemented during the care of pregnant and postpartum women. Professionals included in the present study agreed that PFMT prevents and treats SUI, UUI, and MUI in late pregnancy and the late postnatal period. According to previous evidence, the early prescription of a structured and supervised PFMT can lower UI risk in late pregnancy. However, insufficient information is available to determine whether it prevents or treat UI in the late postnatal period [4]. Moreover, although physiotherapists agree that PFMT prevents and treats fecal incontinence, there is still no scientific evidence supporting its effectiveness [4]. Therefore, it seems that there is an inconsistency between the physiotherapists’ perceptions and the available evidence regarding the PFMT prescription. One of the possible reasons is that, although there is no scientific evidence supporting those results, professionals might identify potential benefits of PFMT prescription in their clinical practice, fact that indicates to physiotherapists that it might be already concluded by the literature.
Another important highlight of the present study is that most parts of the participants disagree that there is sufficient evidence related to the PFMT in the literature. We agree with this statement, as only one previous systematic review reported the certainty of the evidence of PFMT prescription for UI and fecal incontinence during pregnancy and late postpartum[4] and was used to create the evidence table of the present study (Table 3). Therefore, we highlight that efforts must be made between physiotherapists and institutions and/or associations related to Women’s Health education to clarify the real implications of the PFMT.
This study has some limitations. The first one is that the data collection was based on a questionnaire that was not validated, although some questions were adapted from a previous study [17]. However, our instrument was developed by a suitably trained team with clinical experience in the study area and repeatedly evaluated by a group of professionals not included in the present study to ensure that the questionnaire followed its purpose. Secondly, we were not able to evaluate the perception of the patients about the PFMT, one of the aspects that constitute the EBP. However, the main focus of the present study was to analyze the perception of the Brazilian physiotherapists, which we considered a different population. Despite that, recent evidence is showing some barriers identified by incontinence women to practice PFMT [33]. Therefore, we understand that future studies should also focus on the investigation of the patients’ perception about PFMT. Moreover, we analyzed the self-reported knowledge and attitude of the physiotherapists. Although the data collection was blinded to the participant's identity, participants could feel pressure when negatively answering the tested statement or could potentially check the available literature to answer the questions. However, we could still detect an inconsistency between physiotherapists' perception and the available literature, which might represent that participants were not assessing secondary material to answer the questionnaire.
Our results contribute to identification of the knowledge and barriers of Brazilian physiotherapists regarding some aspects of EBP, in addition to behaviors and attitudes related to the evaluation and treatment of pregnant women. Physiotherapists from different regions of Brazil were included in the present study, allowing a broad view of their knowledge, skills and barriers. This fact may be important to support the creation and implementation of strategies that contribute to the improvement of the clinical practice of physiotherapists that work in the Women's Health area, in addition to improving the inclusion of PFMT in the treatment and ensuring effective care for pregnant and postpartum women.