# Perceptions of a 'Pelvic-Floor Friendly' Group Exercise Class in Women with Urinary Incontinence
## 3 Results and Discussion
### Study Aim 2
#### 3.2.2 A Failure to Consider Midlife Women's Needs
For most, it was due to the already covered social aspect of group exercise:  
_\"I went to a class where everybody is 70 plus and I'd be like, yeah, it's great but, you know, socialising, it's been taken out\"._  
But for others, there appears to be a drop in enjoyment due to the lower exercise intensity experienced in these classes. To the best of the researchers' knowledge, no studies have reported the impact on enjoyment from reducing the intensity of exercise from mid/high intensity to low intensity in midlife individuals who regularly participate in high volumes of PA, and who are also forced to permanently reduce their normal intensity level through illness or injury. However, a study comparing the intensities of walking football to that of small-sided running football found the higher-intensity running football was rated more enjoyable by older male and female participants (aged \(\geq\)60 years), although the authors of the study note this may be, at least in part, due to the majority of participants regularly participating in the higher-intensity running football and thus developing a preference toward it [97]. This caveat may also suggest that it is possible an individual's level of fitness influences enjoyment when participating in high-intensity PA, a view further strengthened by a study of non-exercising obese women, which found participants experienced lower levels of enjoyment when undertaking high-intensity interval training compared to moderate-intensity continuous exercise training [98]. While overall, the evidence on which intensity exercise leads to higher perceived enjoyment in physically active adults is mixed, several studies have reported that high-intensity interval training (HIIT) is more enjoyable than medium-intensity continuous exercise [99]. Research hassuggested that at least some of the enjoyment elicited from HIIT may be due it being more time efficient, a factor which could be used to help influence busy midlife women to re-engage or continue with, group PA [99]. Needs Ignored  
Following on from their discussion of attending older women's exercise classes to manage UI during group PA, the conversation orientated to the way the intervention class instructor had delivered the class using, what one participant referred to as, an 'upside-down approach'. As previously outlined, it is standard practice in a group exercise class for a class instructor to provide lower-impact exercises to replace some of the most high-impact exercises, to help prevent pain and exacerbation of any injuries or health conditions. Exercisers can choose to perform these lower-impact exercises if they feel they are at risk, while the rest of the class continues with the normal exercise. However, the intervention instructor was asked to use a'reverse instruction method' for the current study. The reverse instruction method maintains low-impact exercise as the norm and offers higher-impact alternatives for class members who feel their pelvic floor can cope safely. It is worth noting that a medium/high intensity of exercise was maintained throughout the session as much as possible. Surprisingly, given the number of participants in the intervention group who have withdrawn from group PA due to UI, the researcher observed that none of the women during the intervention were avoiding any of the lower-impact exercises. Where the instructor gave higher-impact or higher-intensity alternatives, two women chose to undertake all of these, with two more attempting at least some. Overall, the participants felt this method of exercise instruction gave them more than simply the ability to participate in group PA:  
_\"You don't feel as if you're letting anybody down, I suppose, including myself and the instructors and everything else, because you're doing what everybody else is doing. And if you want to do a bit more, then that's fine, but you're not feeling that, you know, 'Oh no, I better not do that'.\"_  
Participants reported the intervention instruction method helped reduce anxiety and the fear of leaking in front of others.