Why OTs Should Treat Incontinence

Occupational Therapy for the Treatment of Incontinence & Pelvic Floor Disorders

Tiffany Ellsworth Lee MA,OTR,BCB-PMD

Incontinence and pelvic floor disorders have a profound impact on occupation, the daily activities that give life meaning.

Biofeedback Training & Incontinence Solutions San Marcos, TX

Brenda Neumann OTR, BCB-PMD

ProHealth Care-Mukwonago, WI

AOTA Conference April 29, 2012 Slide 2

Incontinence and Occupation

Psychosocial Impact of UI

• UI is recognized as one of the leading causes of

institutionalization of the elderly (AHCPR 1996) • Impairments in bowel, bladder and urogenital

function result in loss of self-esteem, difficulty maintaining a healthy and independent lifestyle, and fulfilling relationships (Hajjar 2004, Nygaard 2003, Bharucha 2005)

• Activities outside the home, social interactions

with friends and family, and sexual activity may be restricted or avoided entirely (Fultz 2004, Handa 2004, Salonia 2004)

From Hajjar, RR. Pyschosocial impact of urinary incontinence in the elderly population. Clin Geriatr Med. 2004; 553-564, viii.

Slide 3

Overview of Presentation

Slide 4

What is Incontinence?

• Incontinence Symptoms/Definitions

• Loss of bladder or bowel control

• Prevalence, Impact and Risk Factors

• The complaint of any involuntary

leakage of urine or stool

• Treatment Options and the Role of

Occupational Therapy • OT Scope of Practice • Resources and Practical Tips

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1

Types of Incontinence

Urge Incontinence

Bladder Incontinence • Urge • Stress • Mixed

• “the urgent need to pass urine and

the inability to get to a toilet in time” (NAFC) • “the complaint of involuntary leakage

accompanied by urgency” (ICS)

Fecal Incontinence

Slide 7

Slide 8

Urge Incontinence

Stress Incontinence (SUI) • “occurs when pelvic muscles have been damaged, causing the bladder to leak during exercise, coughing, sneezing, laughing, or any body movement that puts pressure on the bladder.” (NAFC) • “the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing.” (ICS)

Slide 10

SUI with Pregnancy and Childbirth • • •

• • •

46% urinary incontinence during pregnancy Antenatally, usually transient Postnatally, likely more severe and permanent due to weakened urethral sphincter closure mechanism Relaxin hormone softens all ligaments and muscles of pelvic outlet Partial denervation of pudendal nerve during pregnancy reduces postural tone of sphincter mechanism Complications during labor • poor bladder management, over-distention of bladder • damage to urethral sphincter closure mechanism – influenced by: long first and second stage labor, baby’s weight •

forceps, tearing, or episiotomy damage pudendal nerve

Slide 12

2

Mixed Incontinence • “the complaint of involuntary

leakage associated with urgency and with exertion, effort, sneezing, or coughing.” (ICS) • Symptoms of both urge and stress

incontinence Slide 14

Fecal Incontinence • “the inability to control the passage

or loss of gas, liquid and/or solid stool.” (NAFC) • Usually 1 out of 10 patients with

urinary incontinence experience fecal incontinence. (NAFC) Slide 15

Other Definitions

Other Definitions

• Frequency - “the need to void more

than eight times per 24 hours, although this is dependent on fluid intake.” (ICS) • Nocturia- A complaint of needing to wake one or more times to go to the bathroom. (ICS) • Overactive Bladder- urgency, with or without urge incontinence, usually with frequency and nocturia. (ICS)

• Functional Incontinence – Difficulty

getting to the restroom in time due to mobility or cognitive problems. • Urinary Retention – Partial or complete inability to empty the bladder.

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Chronic Retention of Urine

Urinary Retention

• Leakage that occurs when the quantity of urine produced exceeds the bladder's holding capacity (NAFC) • May result from diabetes, trauma, pelvic surgery, pelvic organ prolapse in women, enlarged prostate in men, spinal cord injuries, or MS. (NAFC)

• Previously called “Overflow Incontinence” Slide 19

Belief Systems

Prevalence of UI (NAFC) • 200 million people worldwide • 1 in 4 women over age of 18 • Two-thirds of men & women ages 30-70 have never talked to their doctor about their bladder health. • 1 in 8 Americans with UI have been diagnosed. • Only 1 in 12 will seek treatment • Women wait > 6 years to obtain a diagnosis after symptoms appear

• “Incontinence is a stigmatized,

underreported, under-diagnosed, under-treated condition that is thought to be a normal part of aging.” (NAFC) • One-third of men and women ages 30-70 believe incontinence is a normal part of aging to accept. (NAFC) Slide 21

Slide 22

Prevalence (NAFC)

Risk Factors • • • • • • • • •

• Top 10 diagnoses for homebound • 25 million in U.S. (est. > 75% women) • >50% LTC patients

Constipation/Straining Age & Race (caucasion-SUI / AA-UUI) Sex (women higher risk than men) Smoking Obesity Occupation (heavy lifting) Physical Activity (sports) Childbearing Family History

Muller N. What Americans Understand- How They are Affected by Bladder Control Problems: Highlights of Recent Nationwide Consumer Research. Urologic Nursing. 2005:25(2): 109-115.

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Economic Costs

Impact of Incontinence • Economic Burden

•

•

The cost of UI and OAB in the U.S. was 32 billion (in year 2000 dollars) -$23 billion -community residents -$9 billion- institutional residents

• Limited social and work activities • Limited sexual/physical activities • Falls/Skin lesions

Costs include: diagnosis and treatment, routine care, consequences (skin conditions, UTI, falls, broken bones, NH admission, longer institutional stay), lost productivity

26% increase in risk of fall (Tromp 1998) 34% increase risk of bone fracture (Brown, JS 2000)

• Fear of embarrassment and odor

Hu TW, Wagner TH. Costs of Urinary Incontinence and Overactive Bladder in the US: A Comparative Study. Urology. 2003;63:461-465.

• Toilet mapping • Depression

Slide 25

Emotional Costs

Slide 26

Quotes From Our Patients • “I don’t like to go anywhere because

• Loss of Independence

I’m constantly looking for a bathroom, so I just stay home”.

• Impaired social interaction • Low self esteem • Loss of intimacy

• “This isn’t something you usually

• Fear of going places

talk to anyone about. It was psychologically affecting me. It made me feel like a hermit. I felt trapped.”

• Anxiety • Bladder begins to control life Slide 27

Treatments For Incontinence

Slide 28

Behavioral Therapy

• Surgical

Recommended as first-line treatment for UI “Behavioral techniques are low-risk interventions that decrease the frequency of UI in most individuals when provided by knowledgeable healthcare providers.”

• Pharmacological • *Behavioral Therapy

(Agency for Healthcare Policy and Research 1996 and the 3rd International Consultation on Incontinence)

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Behavioral Therapy

OT Scope of Practice

Prompted or Scheduled Toileting

• AOTA Occupational Therapy Practice

Framework: Domain and Process 2009

Bowel & Bladder Retraining

Habit Training

Behavioral Therapy

PFM Re-ed

• AOTA Scope of Practice 2009 • State Guidelines

Dietary & Fluid Modifications

Slide 32

Occupational Therapy Practice Framework: Domain and Process -AOTA 2009

AOTA OT Scope of Practice 2009

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The Role of Occupational Therapy in the Treatment of Incontinence

Basic OT Interventions • Assessment and training self-care

• All occupational therapists and

skills

occupational therapy assistants have the education and training to provide the following skills defined as BASIC OT interventions:

• • •

Clothing management Toilet transfers Hygiene

• Recognition of toileting needs • Environmental modifications • Prompted or scheduled toileting Slide 35

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The Role of Occupational Therapy in the Treatment of Incontinence

Basic OT Interventions

“Some OTs may specialize in evaluating and intervening with a specific function, such as incontinence and pelvic floor disorders, as it relates to supporting engagement in occupations and activities targeted for intervention.”

Identification of the need for adaptive equipment or adapted techniques • • • •

raised toilet seat or bedside commode adapted handles or methods for suppository insertion, digital stimulation, and toileting use of adapted clothing fasteners training in adapted techniques for intermittent self-catheterization, and use of urine collection devices

AOTA Practice Framework: Domain and Process 2009

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Advanced OT Intervention

Competency • OTs should acquire specialized training to

Specialized or advanced occupational therapy intervention requires the therapist to understand body functions such as urinary, digestive, and reproductive functions, and involves administering specific tests and treatment for pelvic floor muscle dysfunction.

perform advanced intervention for the treatment of incontinence and pelvic floor disorders. • OTs should demonstrate competency prior to the delivery of services. Methods to obtain competency: -comprehensive continuing education -comprehensive clinical training with a qualified mentor -certification through an accredited training program such as the Biofeedback Certification International Alliance.

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Understanding the Body FunctionsRelevant Anatomy and Physiology

• • • • • • •

Bladder Urethra Uterus Vagina Prostate Rectum Pelvic Floor Muscles

Uterus Rectum Bladder

Levator Ani/ Pelvic Diaphragm Urogenital Diaphragm

Female Pelvis Slide 41

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Tendinous arch of levator ani muscle Piriformis

Piriformis

Rectum

Bladder

Uterus

Rectum

Ischio-coccygeus

Pubic Symphysis

Rectum Bladder

Prostate Gland

Pelvic Floor Musculature

Urethra

Anal Canal

PELVIC DIAPHRAGM/ LEVATOR ANI MUSCLES

Pubic bone

•ILIOCOCCYGEUS Urethra Vagina Urethra

•PUBOCOCCYGEOUS

Vagina Anus

Male Pelvis

Female Pelvic Diaphragm Copyright © 2004, Boulder NeuroTraining Center LLC

•PUBORECTALIS •LEVATOR VAGINAE

Copyright © 2004, Boulder NeuroTraining Center LLC

Clitoris Ischiocavernosus muscle Bulbospongiosus muscle

Vagina

Superficial transverse perineal muscle

Urogenital Diaphragm sphincter urethrae compressor urethrae urethrovaginal muscle

Levator ani

Ischiocavernosus muscle Urogenital Diaphragm Bulbospongiosus muscle

sphincter urethrae compressor urethrae

Superficial transverse perineal muscle levator ani

External anal sphincter

External anal sphincter

Female Superficial Perineal Muscles and Urogenital Diaphragm

Male Superficial Perineal Muscles and Urogenital Diaphragm

Copyright © 2004, Boulder NeuroTraining Center LLC

Copyright © 2004, Boulder NeuroTraining Center LLC

Bladder

Pelvic Floor Function

• Detrusor muscle: Circular and longitudinal fibers

forming a interlacing meshwork

• Support organs • Maintains storage-anal and urethral

closure • Inhibits or permits contraction of the rectum and bladder (the gatekeeper) • Full relaxation is needed to empty the rectum and bladder

Copyright © 2004, Boulder NeuroTraining Center LLC

Copyright © 2004, Boulder NeuroTraining Center LLC

Slide 48

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Bladder Storage and Emptying

Copyright © 2001 Louise E. Marks, M.S.,O.T.R

Advanced OT Intervention

Advanced OT Intervention

Functional assessment of bowel, bladder, and sexual function: • • • • • •

• Assessment of pelvic floor muscle

function related to bowel, bladder, and sexual function (strength, tone, isolation, coordination)

review of medical history, pertinent diagnostic tests and prior treatments interview/self-report symptom diary analysis of habits, routines and behaviors lifestyle impact patient’s treatment goals

• •

standardized digital exam specialized pelvic floor muscle surface electromyography (sEMG) using internal vaginal and/or anal sensors.

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Behavioral Therapy

Advanced OT Intervention • Assessment of pain and soft tissue

• • • • • •

dysfunction related to bowel, bladder, and sexual function: • • •

patient self-report diaries muscle or soft tissue palpation

Slide 53

Diet, Fluid, & Lifestyle Modification Pelvic Floor Muscle Exercise/Kegels Biofeedback Treatment Bowel and Bladder Retraining Urge Suppression Home Programs/Patient Education

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Lifestyle Interventions •Prevention •Weight Loss •Smoking cessation •Relaxation

Fluid and Diet Modification

•Nocturia management

• Eliminate or reduce bowel or bladder

irritants • Modify timing and amount of fluid intake • Modify bowel habits if needed

•Fluid and diet modification

•Facilitate voiding and bladder emptying •Treat constipation Slide 55

Common Bladder Irritants

Slide 56

Other Bladder Irritants

•Caffeine

•Spicy Foods

• Carbonated Beverages

•Alcohol

•Tomato Products

•Coffee/Tea

• Milk or Dairy Products

•Vitamins B & C

•Chocolate

•Sodas

• Sugar • Melons

•Citrus Products

• Artificial Colors

•Artificial Sweeteners

• Concentrated Urine

Slide 57

Common Bowel Irritants

Slide 58

Nocturia Management • Space fluids throughout the day-

• Caffeine

begin early • Limit fluid intake after 6PM • If ankles are swollen at the end of the day, elevate legs and pump ankles a couple hours before bed

• Fatty/Greasy Foods • Alcohol • Milk/Dairy Products • Spicy foods • Artificial Sweeteners

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Diet and Lifestyle Modification

Bowel Recipe

• Bowel Habit Regulation

• 1 cup of applesauce

Goal: Regular and predictable

• 1 cup coarse unprocessed wheat

•

Adequate Fiber (20-25 grams a day) • Avoid straining • Fluids and Exercise • Regular time • Heed the Urge • Avoid constipation • Bowel Recipe

bran • ¾ cup prune or cranberry juice

Begin with 2 TBLs everyday with a glass of water. Increase to 2 TBLs 2x a day if needed. Slide 61

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

Rectum contraction

IAS

Puborectalis (striated, partial contraction)

Rectum

Internal anal sphincter (smooth, partial contraction)

relaxation

EAS

relaxation

Stool

enters anal canal

Anal canal

External anal sphincter (straited, partial contraction)

Puborectalis and Sphincters at Rest

Defecation Reflex

Copyright © 2004, Boulder NeuroTraining Center LLC



Puborectalis contraction



External anal contraction



Movement of stool out of anal canal

 Accommodation

of rectum

Inhibition of Defecation Copyright © 2004, Boulder NeuroTraining Center LLC

Copyright © 2004, Boulder NeuroTraining Center LLC



Rectum contracts



IAS relaxation



Puborectalis relaxation



EAS relaxation

Defecation Copyright © 2004, Boulder NeuroTraining Center LLC

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Pelvic Muscle Exercises Arnold Kegel - 1948

Kegel Exercise • Gently contract the muscle as though you are holding back gas or the flow of urine

• Used to teach patients to strengthen

the pelvic floor muscles • Originally taught using a pressure feedback device

• Keep your abdomen, hips, buttocks relaxed • Don’t hold your breath Slide 67

Kegel Exercises Alone are Often Inadequate

Biofeedback • Small electrical signal monitored

• In current practice, patients are often

with electromyography (EMG)

given a simple handout with limited explanation by their physician. • Research indicates simple written and verbal instructions are inadequate (Burgio 1985). • 30% perform incorrectly even with intensive instruction (Bump 1991)

• Information about an unconscious

process is presented visually on computer screen • Immediate knowledge of muscles becomes available to teach patient how to alter the physiologic process Slide 69

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Surface EMG Assessment Sensor placement

Internal Surface EMG Sensors

Rectal Sensors SRS Multiple Electrode Probe MEP

• Vaginal, anal sensors, single user • External placements (4 and 10

The Prometheus Group Perry/Pathway EMG/Stimulation Sensor

o’clock) • Accessory abdominal muscle identification needed

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SRS Elan

.

Thought Technology Ltd

Vaginal Sensors

Slide 71

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Abdominal EMG Placement

EMG Biofeedback Assessment and Treatment • PFM and abdominal EMG testing • Assess resting tone, slow and fast-twitch muscle fibers-train in 3 positions (supine, sit, and stand) • Valsava maneuver • Reduce PFM hypertonus • Coordination training • Strength and endurance training

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Slide 74

sEMG Tracings

sEMG Tracings:

Isolated tonic pelvic floor muscle contractions: good motor recruitment and release, low pre and post baseline readings

Pelvic floor muscle hypertonus (pre and post elevated readings) weak contractions with abdominal substitution (pelvic floor myalgia)

--------Ten seconds--------

Weak and poorly isolated contractions with abdominal substitution (stress incontinence)

Good relaxation of pelvic floor muscles with bearing down

Good motor recruitment and strength with elevated and unstable readings following contractions: delayed and poor return to baseline (vulvodynia)

Co-contraction of pelvic floor and abdominal muscles when attempting to bear down (pelvic floor dyssynergia, constipation, urinary frequency and hesitancy)

--------Ten seconds-------10uV

2uV --------Ten seconds--------

Vaginal or Rectal Abdominal

Vaginal or Rectal Abdominal Copyright © 2004, Boulder NeuroTraining Center LLC

Copyright © 2004, Boulder NeuroTraining Center LLC

Samples of Surface EMG Biofeedback Displays

Clinical Setting •Cured or Smoked Meat This biofeedback training screen reinforces pelvic floor muscle relaxation. When the rectal EMG reading is below an adjustable threshold, music turns on and advances are made through the maze. Good for use with a pediatric population..

A standard 2 channel sEMG line graph display. The pelvic floor EMG tracing changes color when the microvolt level exceeds an adjustable threshold. Used for pelvic floor muscle assessment and neuromuscular reeducation.

As the patient contracts or relaxes pelvic floor muscles, the sphincter animation mirrors in real time the motor activity. This animation is useful for relaxation, coordination, and strength training.

Marks Software Tools for Pelvic Floor Dysfunction

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Case Study 1

CASE STUDIES

Stress Incontinence

• Stress Incontinence-

Lois is a seventy-two year old woman, mother of three. For two years now she has been experiencing mild leaking with sneezing and coughing.

• Urge Incontinence-

Grace is fifty-seven years old, and works in the front office of a busy travel agency. She is so busy that she will rarely uses the toilet while at work. When she does go to the bathroom, she notices that she leaks before she can get to the toilet, often soaking her underwear.

• Fecal Incontinence-

Lauren is sixty-three and lives alone. Lauren has noticed that her bowel movements are unpredictable. Last month she was out shopping when she had the urge to move her bowels and she could not find a rest room in time, causing her to leak stool.

Copyright 2012-Biofeedback Training & Incontinence Solutions

Case Study 1- Stress Incontinence-Quick Flicks then Sustained

Copyright 2012-Biofeedback Training & Incontinence Solutions

Case Study 2-Urge IncontinenceSustained then Quick Flicks

Copyright 2012-Biofeedback Training & Incontinence Solutions

Slide 79

Copyright 2012-Biofeedback Training & Incontinence Solutions

Case Study 2-Urge Incontinence-Assessment of Quick Flicks then Sustained

Copyright 2012-Biofeedback Training & Incontinence Solutions

Case Study 3- Fecal IncontinenceQuick Flicks then Sustained

Copyright 2012-Biofeedback Training & Incontinence Solutions

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Pelvic Floor Muscle Exercises

Case Study 3-Fecal IncontinenceSustained then Quick Flicks

• 25 repetitions 3x a day • Focus on slow sustained contractions for 10-30 seconds and quick isolated contractions • Progress from supine to standing as skill improves

Copyright 2012-Biofeedback Training & Incontinence Solutions

Slide 86

Bladder Training • Review bladder diary

• Determine longest comfortable interval for patient • Gradually increase voiding interval •

Goals-increase storage capacity, decrease frequency and urgency

Slide 87

Urge Suppression

Stress Strategies-KNACK

• Stay still or sit down

• Squeeze before you sneeze, cough,

• Take some deep breaths and relax

laugh, lift, blow your nose, etc. • Make it a lifetime habit • Requires practice and coordination • Decreases risk for further weakness and prevents leaks

the abdominal muscles • Perform gentle PFM contractions to

calm the urge • Wait for urge to pass • Walk to bathroom at a normal pace Slide 89

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Home Programs

Behavioral Therapy Modalities & Tools • Scheduled toileting (every 2-4 hours) for frail elderly or Alzheimer’s patient with goal to keep patient dry • Timed voiding & double voiding

• Bowel or bladder diary as needed • Lifestyle modifications • PFM exercises 3x a day

•

• Urge suppression techniques

Retention

• Absorbent pads & skin care products • Habit training

• Relaxation exercises if needed

• • •

Enema or laxative to clean bowels Attempt BM at regular time after meal If no BM after 48 hours, repeat enema or laxative

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Behavioral Therapy Modalities and Tools

Behavioral Therapy Modalities and Tools

• Pessaries

• Electrical stimulation

• Dilators

•

Poor sensory awareness

•

Very weak pelvic floor muscles

• Myofascial release and visceral

 Dyspareunia  Vaginismus

manipulations •

• Weighted cones 

Graduated weights



Stress urinary incontinence

Refer to specialist as needed

• Home pelvic floor training units

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Surface EMG Instruments for Home Training

The Prometheus Group

Electrical Stimulation Units Copyright © 2004, Boulder NeuroTraining Center LLC

Thought Technology, Ltd.

Used with internal or external sensors

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Related Patient Populations

Additional Home Training Units • • • • • •

Post prostatectomy incontinence BPH (benign prostatic hyperplasia) Post-micturition dribble Detrusor sphincter dyssynergia Outlet obstruction type constipation Pelvic pain syndromes • Prostatitis • Levator ani syndrome • Vulvodynia

Myself Home Trainer Copyright © 2004, Boulder NeuroTraining Center LLC

Patient’s Goal

Stress Incontinence Case Study

“I want to be able to drink fluids without the fear of leaking. I want to be able to lead a normal life without the embarrassment of incontinence.”

36 year old female Leaks numerous times a day with coughing, sneezing, exercising, and position changes Voids 4 oz every hour Awakens 1-3x a night High intake of bladder irritants Unable to dance/jump on trampoline with children

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Treatment Results

Stress Urinary Incontinence Treatment • Complaint of involuntary leakage on effort or exertion or with sneezing or coughing.

6 weeks (5 visits) later: Completely continent Sleeps through the night Reduced excessive irritant intake Increased water intake from 16 to 60 ounces Voids every 3-4 hours Resumed dancing and jumping with her kids One year later: Remains continent

Treatment options Voiding Diaries/Discuss dietary irritants Education regarding role of pelvic floor musculature and continence Pelvic floor muscle strengthening with or without EMG biofeedback Electrical stimulation if pronounced weakness or lack of proprioception KNACK

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Patient’s Goal

Urge Incontinence Case Study

“I

want to be able to go to church or the store without the fear of leaking. I want to make it to the bathroom without having an accident.”

79 year old female 7 accidents per week in route to toilet Voids 3 ounces on average Nocturia Can not hold urine > 1 minute Drinks 32 oz a day of milk and OJ Limits social outings for fear of leaking

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Urge Incontinence Treatment

Slide 104

Treatment Results

• The urgent need to pass urine and the inability to

get to a toilet in time.

2 months (6 visits) later: From 7 to 0 accidents per week Voiding increased from 3 to 9 oz No longer waking at night Able to hold urine for several min. Increased water intake, decreased irritants 6 months later: Remains continent and is regularly going to the store and church with confidence

Treatment Options: •

Education: use of pelvic floor muscles to inhibit detrusor activity and other inhibition techniques

•

Pelvic floor muscle strengthening with or without EMG biofeedback

•

Neuromuscular relaxation with or without biofeedback

•

Dietary counseling regarding bladder irritants and fluids

•

Bladder retraining

•

Electrical stimulation

Copyright © 2004, Boulder NeuroTraining Center LLC

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Treatment of Post-Prostatectomy Urinary Incontinence

Post-prostatectomy Case Study

• Complaint of involuntary leakage on effort or

exertion along with small amounts urine leakage (dribbling) throughout the day.

65 year old male Continual leaking all day Lacks sensation of bladder urge Wears 2 washcloths per day Nocturia (2x) Limited fluid intake Goal “To stop leaking.” Feared social outings and golfing with friends

• Treatment options Voiding Diaries/Discuss dietary irritants Education regarding role of pelvic floor musculature, continence, and male pads Pelvic floor muscle strengthening with or without EMG biofeedback KNACK Timed Voiding

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Nursing Homes

Treatment Results

• Incidence of UI is estimated at 50% • 22% of women & 56% of men continent at admission

8 weeks and 6 visits later: Continual leakage to no leakage Awakening 2x a night to none Decreased irritants/increased water *Able to resume community activities and golf without fear of embarrassing accident

become incontinent within 1 year • 25% of UI is associated with decrease in function or

mobility • Omnibus Budget Reconciliation Act mandates

appropriate treatment and services. • Useful Interventions:

-Bladder retraining -Prompted voiding -Habit training - Scheduled Toileting Newman, D. (2004) Urinary Incontinence in Long-Term Care Facilities: Current Clinical Practice Slide 109

Slide 110

Nursing Homes-Case Example

Men • Post-prostatectomy incontinence

Nancy-83 Year Old Woman with Diabetes

-Pre-surgical training may reduce severity (Burgio 2006) Patient Goal: transition to assisted living Problem: Large episodes of urinary incontinence at rest and sit to stand Factors: • Poor sensation of bladder filling/urge due to diabetes • Difficult to transfer-tends to wait too long Behavioral Strategies: • Prompted voiding initially • Teach patient to follow timed voiding schedule

• Useful Products -

-

-

Specialized pads –available through Home Delivery of Incontinence Supplies (HDIS ) 1-800-269-4663 or www.hdis.com Afex-Incontinence Management System 1-877-272-8763 or www.arcusmedical.com Penile Clamps-C3 Incontinence Clamp 1-800-345-5642 or www.srsmedical.com

Slide 111

Useful Products for Men

Slide 112

Take Home Tips • Urge Control Strategies • Dietary Modifications • Controlling Constipation • Lifelong Habits-Exercise • Scheduled Voiding • Importance of Empathy • Patient Comfort Slide 114

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Resources for Training and Certification

Resources for Training & Continuing Education

Biofeedback Certification International Alliance Telephone 1-866-908-8713 or www.bcia.org -offers certification in pelvic floor muscle dysfunction biofeedback

-Society for Urologic Nurses and Associates 1-888-TAP-SUNA www.suna.org -Annual spring symposium related to incontinence and pelvic floor disorders (multi-disciplinary)

Biofeedback Training & Incontinence Solutions Telephone 1-512-557-6310 or www.pelvicfloorbiofeedback.com -hosts a 3 day course annually in April and September which fulfills didactic and practicum requirements for certification (OT faculty)

-Biofeedback Foundation of Europe Tel/Fax +31 84 83 84 696 or www.bfe.org -offers on-line didactic and practicum training toward certification (OT faculty)

Marquette University Telephone 414-288-3097 or www.marquette.edu/chs/pt/cont-ed -hosts a 4-day course annually in June which fulfills didactic and practicum requirements for certification (OT faculty)

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How to Get BCIA Board Certified

Good Reference Books

• Must be licensed as a nurse, PA, MD,

• • • • •

Laycock J, Haslam J. (Eds), (2010). Therapeutic Management of Incontinence and Pelvic Pain, Pelvic Organ Disorders. Springer, London. Cram, J. R. & Kasman, G. S. with Holtz, J. (2010). Introduction to Surface Electromyography. Gaithersburg, MD: Aspen Publishers. Schwartz, M. S. & Associates. (2005). Biofeedback: A Practitioner'sGuide (3rd ed.). New York: Guilford Press. (Chpts 2628)

OT, PT, PA or psychologist COTAs and PTAs may be a board certified technician 28 hours of didactic education 18 hours of mentoring Written certification exam Recertified every 3 years with 36 accredited + 20 elective hours of CE in pelvic muscle dysfunction Slide 117

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Resources & Professional Organizations

Good Reference Books • • •

Burgio K. (1989). Staying Dry. Baltimore, MD: John Hopkins University Press. Newman DK. (1999). The Urinary Incontinence Sourcebook. Los Angeles, CA: Lowell House. Doughty D. (2006). Urinary & Fecal Incontinence: Current Management Concepts, Third Edition. St. Louis, Missouri: Mosby Elsevier.

• • • • •

•

National Association For Continence (NAFC) www.nafc.org International Continence Society (ICS) www.icsoffice.org Society of Urologic Nurses and Associates (SUNA) www.suna.org American Urologic Association (AUA) www.auanet.org The Simon Foundation for Continence www.simonfoundation.org Biofeedback Certification International Alliance (BCIA) www.bcia.org International Foundation for Functional Gastrointestinal Disorders (IFFGD) www.iffgd.org National Kidney and Urologic Diseases Information Clearinghouse http://kidney.niddk.nih.gov/ Biofeedback Foundation of Europe (BFE) www.bfe.org

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Clinical Practice Resources

Our contact information

• The Urinary Incontinence Manual 3rd Edition-www.progressive therapeutics.com

Tiffany Ellsworth Lee Cell phone 512-557-6310 or email [email protected] www.pelvicfloorbiofeedback.com Brenda Neumann Phone 262-928-8597 or e-mail [email protected]

• Gynecologic Physical Therapy Manual 2nd Edition-published by the APTA Section on Women’s Health- available online at www.womenshealthapta.org

• Beyond Kegels Book II, 2nd Editionwww.phoenixcoresolutions.com Slide 121

Slide 122

Special Thanks • To Louise Marks MS,OTR,BCB-PMD for allowing the use of some of her slides and drawings. Additionally for her mentoring and encouragement. • Jeannette Tries, PhD., OTR for her role as an OT pioneer in this field. Additionally, for her mentoring and ongoing support.

Slide 123

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