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Incontinence competence
Monday October 1, 2012

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Common pelvic floor disorders

Pelvic organ prolapse occurs when the pelvic muscles and tissue become weak and can no longer hold the organs in place correctly. In uterine prolapse, the uterus can press down on the vagina, causing it to invert or come out through the vaginal opening. In vaginal prolapse, the top of the vagina loses support and can drop through the vaginal opening. Symptoms can include an inability to empty the bladder completely and frequent urinary tract infections.

Urinary incontinence happens when the bladder drops down into the vagina and can cause urine leaking without a woman’s control. Other symptoms might include urgency to urinate, frequent urination and painful urination.

Anal incontinence occurs when the rectum bulges into or out of the vagina, making it difficult to control the bowels, or when there is damage to the anal sphincter, the ring of muscles that keep the anus closed.

Source: National Institutes of Health

Resources for PTs

Tools:

A variety of tools can be used in therapy for strengthening the pelvic floor muscles, Kassai said. Among them:

• StepFree vaginal weights. A set of five vaginal weights that builds tone and endurance in the pelvic floor by SeekWellness (SeekWellness.com)
• KegelMaster. A spring-loaded device that adds resistance directly to the pelvic floor by Wellness Partners (Store.WellnessPartners.com)
• Magic circle. A small piece of resistive Pilates equipment offered by various vendors
• AeroPilates reformers. These are economical Pilates reformers that place resistance on core muscles, by Stamina Products Inc. (StaminaProducts.com)

Training:

PTs can obtain training on pelvic floor and incontinence therapies through several resources:

• The Herman & Wallace Pelvic Rehabilitation Institute, founded by Holly Herman, PT, DPT, OCS, BCB-PMD, and Kathe Wallace, PT, BCB-PMD, provides training courses in pelvic floor/pelvic girdle dysfunction. The New York-based institute provides continuing education throughout the country. For a list of upcoming classes, go to hermanwallace.com.
• American Physical Therapy Association, Section on Women’s Health offers members a certificate of achievement in pelvic physical therapy. Known as CAPP, the program provides specialized training. Check womenshealthapta.org for upcoming classes.

Source: Kathryn Kassai, PT

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The prevalence of pelvic floor disorders in women — that often result in incontinence problems — is slowly coming to light in this country with the help of physical therapists.

Some 34 million Americans suffer from urinary incontinence because of weakened pelvic floors, and more than half of women will experience incontinence at some point in their lives, said Kathryn Kassai, PT, CSE, owner of Praxis Physical Therapy in San Pedro, Calif., and co-author of "The Bathroom Key," a guide to physical therapies that address incontinence.

In addition to the embarrassing emotional strain of incontinence, it has become the leading cause for women entering nursing homes, Kassai said. Fortunately, the underlying issues of incontinence can be addressed by PTs through exercises and conditioning. The therapies are so effective that most insurers now cover it, she said.

"Some women’s health physical therapists are working extremely hard to inform the lay public that PT provides a natural, noninvasive cure for incontinence, frequency, nocturia, prolapse and pelvic pain," Kassai said.

"Incontinence is one of the most recent things to come out of the closet when it comes to women’s issues," said Shona Woods, RPT, women’s health physical therapist, Winfield (Kan.) Healthcare Center.

Treatment approaches

PTs can be crucial healthcare providers in treating urinary incontinence because of their role in both assessing and treating musculoskeletal conditions. "In listening to my clients, I hear them say things like, 'I urinate a little bit when I sneeze,’" Woods said. "That’s how it starts with many women. Then they begin training their bladder in an abnormal pattern."

That pattern can progress on to urgency and frequency problems, then urge incontinence, Woods said. Soon the bladder is controlling the person, instead of the other way around, she said.

Kegel exercises work for stress incontinence, but are usually not effective for urge incontinence, which requires retraining the bladder to resume holding a larger volume and to empty only on demand as it used to do, Woods said.

Woods said she teaches patients with urge incontinence strategies to delay or distract themselves from going to the bathroom every time they feel the bladder signal. She tells patients that a normal bladder needs draining only every three to four hours.

"They come back a week later and ask why somebody didn’t tell them that before," she said. Most patients need just three to five visits over a couple of months to be back in control of their bladders, she said.

Jill Arnold, PT, DPT, owner of A Woman’s Touch Physical Therapy in Sykesville, Md., asks her clients to keep a bladder diary to help with behavioral retraining of the bladder. She also provides a list of foods that can be bladder irritants, such as orange juice, which clients should avoid while retraining.

"One exercise we use is called 'the elevator,’ where the patient contracts and relaxes the pelvic floor by degree from slight to medium to hardest and then comes back down," Arnold said.

Biofeedback, using equipment such as a Pathway Machine, helps patients to see the pelvic floor muscles and how they react to Kegels and other exercises, Arnold said.

Training with a Pilates reformer machine also offers systematic resistance on the pelvic floor (and other core muscles) to reduce stress incontinence and make urge suppression techniques more effectual, Kassai said.

Recent studies

Kassai said a landmark study published in the August 2010 issue of American Journal of Obstetrics and Gynecology concluded that pelvic floor muscle training is without adverse effects and can be used as treatment for prolapse. Physical therapy was successful in reversing pelvic organ prolapse by one full grade in women with stage II and stage III prolapses after just six months of exercise.

"In light of recent FDA warnings against the implantation of non-absorbable surgical mesh, pelvic floor rehabilitation provides a welcome alternative for the hundreds of thousands of American women who undergo bladder suspension surgeries annually," Kassai said.

An Australian study conducted in 2011 shows incontinence has a broader patient cohort than originally thought, extending beyond women who have had children, gone through menopause, or have had complications in the core or pelvic muscles. The Monash University, Melbourne, study found that 12.6% of 1,000 healthy women ages 16 to 30, who had never been pregnant, were incontinent. "This shatters the misconception that incontinence only occurs after childbirth or at menopause," Kassai said. •

Teresa McUsic is a freelance writer.


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Monday October 1, 2012
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