Reviewer’s report
Title: 
Mechanisms of Pelvic Floor Muscle Training for Managing Urinary
Incontinence in Women: A Scoping Review
Version: 
0 
Date: 
10 Jan 2022
Reviewer's report:
Examining the evidence addressing the biological rationale for the effects of
pelvic floor muscle training (PFMT) for urinary incontinence in women is a
worthwhile endeavour. If there is evidence of a clear relationship (or evidence of
no relationship) between the proposed mechanism of action (e.g. an increase in
PFM strength) and PFMT outcome (e.g. decreased leakage on a cough test) then
we certainly have some thinking to do about why there is some evidence the
intervention is effective.
While much of the review process is reported well, my primary concern is that
this is not a critical interpretive synthesis (CIS). While CIS typically has theory
development as a focus, this research is examining the evidence for each part of
the theory (rather than developing theory) and does not present the synthesising
argument that is the expected outcome of CIS. Other typical features of CIS are
also absent (e.g. open research question, iterative searching, wide range of
sources, inclusion of qualitative and quantitative evidence, inductive analysis,
and so on). The authors may find the recent publication from Depraetere et al
2021 (and the works cited therein from Dixon-Woods et al, Schick-Makaroff et
al, and Tricco et al) helpful in understanding my contention this is not a CIS. 
I think it likely this review fits better with the intent of a scoping review (see
Arksey & O'Malley 2005). A common reason for a scoping review is examine
the 'state' of the existing evidence. This is what the researchers have done, and
usefully examined and summarised the 'state' of that evidence in the three
categories proposed by Bø (2004) as the underlying mechanisms/biological
rationale for PFMT. Further, the authors' inclusion of the PRISMA and SWiM
checklists suggest, they also, recognise that their approach has more in common
with systematic review that CIS. I have, therefore used PRISMA-ScR (Tricco et
al 2018) as a guide to good reporting for this research.
The following items are addressed: 5, 6, 7, 8 (although recommend the full
strategy for one database is appended), 9, 11, 17, 18, 20, 21
These items are not applicable for scoping reviews: 13, 15, 16, 22, 23
Item 1 Title: Identify the research as a scoping review (if this is what it is). Add
'women' as the paper only addresses evidence from this population.
Item 2 Abstract: Ideally, reduce the background and increased reporting of
methods - adding material about how data were charted/analysed.
Items 3 &4, Rationale & Objectives: will be addressed in determining what type
of review this is and explaining selection of review type.
Item 10 Data charting: please address - while the tabulated results are suggestive
of the charting a brief explanation is of the approach (consistent with the
research objectives) is needed. I would also like to see the study types
documented; I am interested to know where these data were found - e.g.
prospective or retrospective cases (with or without controls), secondary analysis
of randomised trials, responder analysis within a primary trial report etc. 
Items 12 & 19 Critical appraisal: the rationale for not doing this (not a
requirement in scoping reviews) is explained. However, I would like some
comment on the appropriateness of the approaches to examining association and
to see the data supporting the statement that the studies were underpowered for
these analyses - how was this assessment made and where are these data found
(my apologies if I missed it)?
Item 14 Synthesis: more detail is needed here. It seems that a descriptive or
narrative summary was chosen. Also, please avoid study counting, e.g. '7 out 10
studies found a statistically significant association' or similar types of statements.
What is more important is strength of association (and robustness/precision of
the estimate of association) and the consistency of the association (or not) across
the studies in each of the three categories. 
Item 24 Summary of evidence: The discussion of PFMT programme
heterogeneity is important. At the same time, this heterogeneity is not surprising
(especially in the enhancing strength category) as there is no 'absolute' set of
parameters for strengthening that I know of, and the boundary between strength
and endurance training isn't absolute either. There is good guidance from august
bodies such as ACSM on resistance training for novice exercisers. If a consistent
effect were seen (association between mechanism and outcome) even with some
intervention heterogeneity (if this were within the boundaries of reasonable
exercise prescription according to ACSM guidance) then this would increase our
confidence that such generic guidance is reasonable in the context of PFMT. On
the other hand, if prescription well outside those boundaries showed the same (or
a different) pattern of association that would also be informative. For instance, in
Table 4, I see some programmes have parameters more consistent with resistance
training for muscle hypertrophy such as (near) maximal contractions and
exercise 1 to 3 times a day whereas others recommending 45 contractions per set
or exercising 6-8 times a day seem inconsistent with ACSM guidance. I wonder
if you observe any pattern if you look at the data that way or if such an analysis
is reasonable? On a separate note I am not sure why there is a discussion of the
potential impact of levator ani tears. This was not (apparently) a review question
and the data are not 'charted' in ways that support this summary. This is not to
diminish the importance of this discussion point, however this identified
evidence gap should appear in the results first? One advantage of scoping
reviews is the somewhat 'emergent' nature of results - when looking for evidence
gaps we don't always anticipate what they'll be and this seems to be an important
one?
Item 26 Conclusions: There is no doubt evidence gaps were found. Is there any
particularly notable evidence gap, or gap that that needs addressing with some
urgency?
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