Dementia

It’s hard to see our loved ones grow old: wrinkles framing their face, locks of hair fading to grey,  their once quick steps now shuffled. The truth of the matter is, these are some expected normals of aging. What is NOT normal is a once-functioning bladder and bowel now leaking urine or feces.  This topic can be much harder to discuss with our loved ones, but communication is imperative to improve the quality of life for our elders. Research shows that urinary incontinence is associated with a higher risk of infection, depression, loneliness and risk of institutionalization. The good news is there are options to help manage bowel and bladder function and mitigate these associated risks.

The first step is bringing up the topic in a simple and direct manner. Ask questions such as, ‘Do you have any difficulty with bladder control?’, or ‘Does urine ever come out when you don’t want it to?’. If you believe this conversation may upset your loved one, try speaking to their health care provider privately, before their next visit. Don’t worry about being using correct medical terminology, just voice your concerns about what your loved one may be experiencing.

Management techniques include influencing toileting behaviors and changing lifestyle habits. Some elders may benefit from being prompted to use the restroom by gentle reminders, such as  ‘Would you like to use the toilet?’, since there is a decreased sensation of bladder filling with aging. Additionally, try establishing a routine around when they would be likely to go to the bathroom. For example, the most common times for bowel movements are upon awakening and after meals. Modifying lifestyle habits can include increasing fluid intake between 48-64 oz per day, spacing fluid intake throughout the day,  and increasing plain water compared to other fluids.  Try limiting beverages with caffeine and carbonation that may be irritating to the bladder.

A pelvic floor physical therapist can provide in-depth and individualized care to help manage bladder and bowel control. Your loved one may require pelvic floor muscle strengthening, relaxation, or a mix of both, for improved function and control over their bowel and bladder. Therapists can also provide education regarding appropriate voiding schedules, lifestyle modifications and environmental adaptations specific to the patient.

 

Dementia and Urinary Leakage

If you know someone with dementia you likely see the obvious forgetfulness: not remembering their favorite meal at the diner or having a difficult time recognizing the faces of their loved ones. But what we oftentimes overlook is how dementia can impact hygiene. Many people with dementia experience a form of bowel or bladder leakage. Sometimes it occurs because they simply can’t find the bathroom but more often than not, they are unable to feel the sensation that they need to relieve themselves. Creating a toileting schedule for your loved one can make all the difference. It is typical for the average adult to urinate every 2-4 hrs and to have at least one bowel movement daily, typically in the morning. Creating a spreadsheet that includes toileting times as well as any other events happening that day can help your loved ones to get through their day.

On the other hand, if they are having trouble navigating to the bathroom and finding their destination you can help them by implementing a few changes to the surroundings. Arrows on the floor may be utilized to mark the path to the bathroom.  Light up toilet seats or colorful toilet seats can also help direct them to their target. And lastly but most importantly, if seeing their reflection in the mirror is distressing or confusing it may be helpful to cover the mirrors. If you know anyone that is having trouble getting to the bathroom or experiencing leakage on the way to the bathroom them may need pelvic floor physical therapy.

 

When having pain becomes a real pain

You’re walking to the bathroom in the middle of the night when suddenly- whack! Your toe clips the door stop. Typing it even makes me cringe.  That’s acute pain.  The sensation that occurs to let us know that something potentially dangerous is happening at a point in our body in the moment.  We need this sensation to keep our body parts safe and avoid allowing them to dangle in a vat of boiling water or allow the rusty nail to hang out for a week in our foot, leading to bigger problems.  However, there’s a whole different category of pain that plagues a huge portion of Americans- chronic pain.   This is pain that is present for greater than 3 months and leads to disability and time away from work and recreational activities and costs the healthcare system hundreds of thousands of dollars.  So what’s going on in chronic pain? We’re not kicking the door stop for 3 consistent months.  In fact, oftentimes chronic pain leads to people spending long periods of time resting, seemingly as far out of the way of danger as possible.  So why is the pain still there?

The answer to this question is actually astoundingly complicated, but we can try to skim the surface.

Imagine that all of the nerves in your body are always in listening mode, buzzing along, looking for something interesting to pick up.  When they intercept a big enough sensation or stimulus, it causes them to jolt, rising above a threshold line. This message then sends to the brain. Think back, however, to when you get a papercut or stub your toe particularly hard. Does the pain drop to 0 the second that the stimulus stops? No, it may take a few minutes, hours, or days for that area to stop feeling tender.  So that level of nerve activity is slowly lowering back down to normal.  But what if a second insult occurs before the sensitivity has returned to its baseline level? Now that jolt rises back up and maybe takes even longer to return down.  If a body part has sustained multiple insults over a relatively short period of time, the nerve will now stay sensitized, near that threshold of alerting the brain at all times.  Now it takes hardly any stimulus to get it to jolt up and tell the brain “something’s happening over here again!!”  It may start alerting the brain for completely innocuous changes like soft touch, stress, hot or cold, or changes in joint positioning.  All these things now rise above that threshold and the brain thinks “oh no- we’re in trouble again- code it as pain!” This person now thinks that any occurrence at the body part means danger and may limit their activity to try to avoid hurting themselves.

The important thing to know is that the experience of pain does not always indicate that tissues are in trouble. In the case of long term, chronic pain, it means that your alarm system is malfunctioning.  Lowering pain does not arise solely from healing the body part, which is certainly happening over time, but also requires fixing the alarm system.  Your physical therapist will work to improve the health of the painful body part with exercise, postural changes, manual therapy, etc.  However, she will likely also recommend alarm-fixing strategies that may at first not seem like a priority when you’re trying to feel better. However, these interventions are integral in achieving lowered pain.  These are things like deep breathing, meditation, gentle movements or exercise to bring more blood and nutrients to the area, and simply understanding this alarm system phenomenon. As the resting nerve excitement lowers, greater movement and activity can be performed without triggering the alarm and the person is able to get back to work, fun, and feeling like themselves.

 

Treatment for Dyspareunia (Painful Intercourse)

As a pelvic floor physical therapist, I treat women of all ages who are dealing with dyspareunia, or pain with intercourse. Dyspareunia is what I call an umbrella term, which means it is very general and doesn’t tell us why a woman is having pain. There are many diagnoses which fall under the category of dyspareunia. One common cause of pain with intercourse that I see is overactive pelvic floor muscles. The pelvic floor muscles are a group of muscles that run from the pubic bone to the tailbone. They have several functions including: Supporting your organs, keeping you continent and sexual appreciation. These muscles form a ring around the vaginal opening and surround the vaginal canal deep inside, so if they are overactive they can contribute to pain. This pain is often described as sharp and burning or sometimes a deep, aching pain. Some women report it feels like there is a barrier at their vaginal opening that prevents their partner from penetrating.

Treatment for pain with intercourse involves manual therapy to decrease muscle tension, instruction in stretching to lengthen short muscles and training in relaxation of the pelvic floor muscles.

In my practice I also find that dilators combined with manual therapy can be very beneficial in decreasing pain with intercourse. Dilators are a medical device that can be used to help “dilate” or expand the vaginal opening. Patients are taught during their physical therapy appointments how to relax their pelvic floor muscles and use dilators at home to practice relaxing these muscles while inserting something vaginally. Typically women start with a small size and gradually work up to a dilator that is comparable or slightly larger than the size of their partner.

I encourage all women who are having pain with intercourse to have an evaluation by a pelvic floor physical therapist to address any muscle over activity. Physical therapy and a dilator program really work best together. In the past I had two women that I started treating the same week who had pain with intercourse. Their histories were very similar. One patient came weekly for physical therapy for eight weeks, then every other week for two visits. At the end of the three months she was having intercourse without pain. The other patient came weekly for two weeks then decided to work on her dilator program on her own at home and stopped coming to physical therapy. When I followed up with her three months later, she was still using the same dilator size as when she stopped coming to see me and had made no progress. Having a physical therapist who can guide you through any issues that may come up when using your dilator and treat your muscles is extremely valuable and in my experience gets women better faster.

Often overactive muscles are at least a contributing factor to pain with intercourse if not the cause. If you have pain with intercourse, please talk to your doctor about getting a referral to see a pelvic floor physical therapist.

Postpartum Exercise – Why You Should Proceed with Caution

Waiting in line to check out at the grocery store, it’s hard not to catch headlines about a celebrity getting her “pre baby body back” after delivery or someone else “still hanging on to their baby weight.”  It seems like there’s a lot of pressure on new moms to get back to grueling exercise as soon as possible. However, as women try to jump right back into the same types of workouts they were performing pre-baby, we see many people really hurting themselves.

The misconception out there is that once you deliver, your body is ready to jump up and get back to all of its normal activities. In actuality, regardless of the method of delivery, even very straightforward childbirth is one of the largest traumas an average body will go through in a lifetime.  You would not recommend a person return to Cross fit 2 weeks after a serious car accident- your pelvic tissues need similar healing time periods.

The following wisdom was shared with me by midwives at Austin Area Birthing Center:

Week 1 postpartum: IN the bed.  That means laying down. You may get up to go to the bathroom. All baby care can be performed in the bed or at bedside. Others should be responsible for cooking, housework, running after additional children.  Do not be entertaining visitors. Sleep as much as your baby will allow and eat nutrient rich foods to replenish your energy stores and healing capabilities.

Week 2 postpartum: ON the bed.  You are still mostly sedentary, but can now sit up to interact with baby, nurse, take slightly longer showers, sit in the bath.  You are not doing chores or running errands.

Week 3 postpartum: NEAR the bed. Get up and combine some quick ingredients for a snack or walk around the house without lifting anything heavier than baby.  Your day is still mostly comprised of rest and baby care, but you are not going grocery shopping and are not going out to exercise.

In the realm of exercise, gentle walking is the best way to start getting back around week 4.

Why so strict? Your uterus needs to be resting to shrink back to its original size and, pending you had a vaginal delivery, your pelvic floor was just stretched to its extreme and needs to slowly return to a functional length.  Don’t pay it the respect it deserves? Your organs may start descending downward and result in prolapse, urinary leakage, or bowel dysfunction.  Tears will be very painful and have a difficult time healing if tissues are strained. Also, your placenta detached from the uterus and left a salad-plate-sized open wound behind.  Bleeding slightly more one day? You opened up your scab by doing too much.

We want you to get back to exercise, but it needs to be done slowly.

Contact a pelvic floor physical therapist for assessment and a rehabilitation plan to allow you to get back to your favorite form of exercise safely.  We’d rather see you for 1-2 visits postpartum to make sure you’re safe and have a plan to reach your workout goals than see you down the road when you’ve already done damage.

Multiple Sclerosis

Multiple Sclerosis (MS) is a disease that affects the central nervous system. When the immune system attacks the myelin, which is the protective coating around the nerves, it results in a process called demyelination. The exact cause is unknown, but is believed to be contributed by a combination of genetics, environmental factors and immune system deficiencies. Common symptoms include fatigue, weakness, blurred or double vision, changes in balance or coordination, pain, and impaired attention or concentration. How does this relate to the pelvis? Unfortunately, with this patient population, up to 80% have bladder dysfunction, more than 40% experience constipation, and 91% of men and 72% of women report sexual dysfunction, according to some studies. Most common bladder dysfunctions include urinary urgency, frequency and incontinence. This happens because the demyelination process affects telling the bladder muscle and pelvic floor muscles what to do.  Constipation is a common result not only from changes in nerve function, but also due to a lack of inactivity as weakness and fatigue worsen. Sexual function changes include decrease in sensation, vaginal dryness, erectile dysfunction, and reduced libido.

Research in this patient population is limited, but shows that the best candidates for pelvic floor therapy are those who get treated in the early stages of MS. Pelvic floor physical therapy, with or without the use of biofeedback, has been shown to improve urinary incontinence, nocturia (nighttime voiding), and bladder emptying. Patient education for behavioral modifications including timed voiding, bladder training, and fluid and dietary management assist with improved bladder storage. Conversely, improved bladder emptying can be improved by techniques for triggered reflex voiding, muscle training for both the pelvic floor and abdomen, and positioning. Extensive research has been performed for managing constipation utilizing abdominal massage; this massage helps facilitate fecal matter through the colon. A pelvic floor therapist can provide education on direction, pressure, intensity and frequency of massage routine for optimal results. In regards to sexual function, a skilled physical therapist can assess pelvic floor muscle tone, flexibility and ability to relax for optimum function in both men and women. It may also be important to look positioning, lubricant, mindfulness and fatigability for improved intimacy. With this in mind, please speak up to your provider regarding pelvic health as symptoms may change over time.

 

 

Irritable Bowel Syndrome

Patients who participate in pelvic floor physical therapy can present with bowel dysfunction which encompasses a myriad of conditions from constipation to the other end of the spectrum being fecal incontinence (FI).  As a fairly new pelvic floor physical therapist having worked at Sullivan PT for 1 year and 3 months, I admit that I struggle with resolving bowel issues.  I have learned that there is a fine balance that needs to be figured out with regards to gastrointestinal (GI) function, primarily gut health, as well as the musculoskeletal component including addressing any muscle tension and connective tissue restrictions within the pelvic girdle or addressing pelvic floor muscle weakness.  I find that one of the main difficulties I have is setting the right expectations in terms of “healing time” as like with any other systems, each person’s body responds differently to physical therapy.  For FI, more often than not, the time frame for symptom improvements tends to be a higher duration due to the time it can take for a muscle to get stronger, physiologically speaking.

Since I have struggled with this condition, I took an opportunity to do some research and found a couple of articles which delved into Irritable Bowel Syndrome (IBS) as well as FI.  In the article I found regarding IBS, patients tend to have tense pelvic floor muscles.  An effective PT treatment involves providing education and prescribing exercises to address behavioral aspects that contribute to symptoms such as incorrect toilet posture, prolonged time spent in the toilet, and use of inappropriate cues to trigger need to defecate.  This information was provided in the article which was called “Treatment of irritable bowel syndrome” written by Chamara Basnayake, MD.  On the other hand, the article regarding FI mentioned that sacroiliac joint (SIJ) pain and pelvic ligaments can contribute to fecal leakage due to the effect on the nerve which innervates GI organs.  This information was provided in the article which was called “Faecal urgency and pelvic pain: a case study implicating pudendal nerve entrapment” written by Peter Dornan, PT.