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

Background: Pelvic floor dysfunction (PFD) remains a common yet undertreated complication after stroke, involving urinary, bowel, and sexual issues with significant effects on quality of life. Previous scoping reviews identified gaps in long-term data, best practices, and coverage of bowel and sexual areas.Objective: This RCT systematically addressed identified research gaps by evaluating sustained efficacy, home-based maintenance, dosing optimization, adjunctive biofeedback/NMES, bowel and female sexual protocols, partner impacts, guideline integration, assessment reliability, quality-of-life correlations, and prognostic factors.Methods: 420 chronic stroke survivors with PFD were randomized to standard PFMT, intensified PFMT, PFMT + biofeedback, or PFMT + NMES for 16 weeks, followed by self-managed maintenance up to 12 months.Results: Sustained improvements were observed in 84% of participants at 12 months, confirming previous findings; adjunctive NMES showed superior results in bowel recovery, while biofeedback was more effective for female sexual function. Perineometry proved to be more reliable.Conclusion: Multimodal approaches provide lasting, domain-specific benefits that justify routine clinical use.Keywords: stroke rehabilitation, pelvic floor muscle training, biofeedback, neuromuscular electrical stimulation, urinary/bowel/sexual dysfunction, long-term outcomesClinical 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.Novelty, Significance, and Impact: As the largest and most comprehensive trial to date on post-stroke PFD, this study offers definitive Level 1 evidence across underrepresented areas, directly informing international guidelines revisions.