Exploring Symptom Variability and Straining in Pelvic Health

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how to incorporate geriatric treatment principles into practice to address pelvic floor concerns with older adults.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.

CHRISTINA PREVETT Hello everybody and welcome to the PT on ICE Daily show. My name is Christina Prevett. You saw me on Monday. I am one of your division leads for both the geriatric and the pelvic health division and you guys got stuck with me twice. If you saw the episode on Monday, you can definitely see that my voice is better. So I don't have the same sickness. So hopefully my voice will be a little bit more tolerable for today's podcast. Today we're gonna be talking about how fitness-forward geriatric clinicians do pelvic well. And one of the things that I often will get asked about is, Christina, it seems really weird that you're in both the geriatric space and the pelvic health space speaking to pregnancy and postpartum. How the heck are these two things connected? And they are a lot more similar than you think, especially when it comes to the quality of our care. What I mean by that is that we are not as fitness forward as we need to be in both the geriatric and in the pelvic health spaces. And there is a significant amount of under dosage that happens in both places. And in our older adult course, we talk a lot about this fitness forward mindset and we try and do the ultimate reframe, right? We worry about the cost or risk of loading people and our thoughts are, what is the risk if we don't? And What is the risk if our person gets a little bit weaker or they have an exacerbation of congestive heart failure and now they're five pounds heavier and they were barely getting up from a chair or using their hands when they didn't have that five pounds? We ask, you know, if they have low bone mineral density and we don't give them the resiliency to reactive step when they have a perturbation, what is the risk when they fall of having a fracture versus somebody else? And that reframe is potent, right? Because it eliminates a lot of the fear and it gets us having a sense, or at least it does for me, a sense of urgency with respect to getting individuals moving. When I see individuals in pelvic health, a big part of my clinical practice right now is postmenopausal females. who are struggling with incontinence or other type of pelvic health conditions, and have underlying muscular weakness or muscular reserve issues. And when I step back and I zoom out and I see that the geriatric space, we tend to underdose. In the pelvic health space, we tend to underdose. My goodness, when you slam those two things together, we see that the bias is to keep people on the table doing Kegels, or we don't even offer them pelvic health services because we assume that leaking and incontinence is a part of aging. and it's something that they have to deal with and it's part of being postmenopausal and have had babies 50 years ago and therefore we're not going to address it. Today I want to talk to some of the literature that says that we actually need to prioritize that fitness more. When we look at aging physiology of the reproductive system, we see that as men and women transition through menopause or andropause, right? Menopause blunting of female sex hormones, andro blunting, but not removal of the male sex hormones, AKA testosterone, that we see a rise in pelvic floor dysfunction. For females, there are one in four individuals are struggling with pelvic floor dysfunction that increases with age. For males, significant increases in pelvic floor dysfunction happen because many of our younger or middle-aged men, not all, but the rates of pelvic floor dysfunction are much lower and they start to increase with age, right? So pelvic floor dysfunction is talked about a lot more in the female space because it's more common. It is definitely more common as we get older. And when we are thinking about incontinence, we are thinking about different types, right? We have stress incontinence, that is more of a mechanical issue where inner abdominal pressure in the belly is exceeding the ceiling pressure of our pelvic floor to be able to close our holes, our urethra and our anal sphincter. And if we don't have enough of that capacity to close those sphincters off, then we pee or poop or pass wind when we don't mean to. Urge incontinence is that we get the urge to go to the bathroom and then we don't have the capacity or we have a very sudden behavioral intervention where I have to go to the bathroom and I have to go right now. I get the urge, I can't defer that urge, I have to go right now. That's very largely outside of any pathology in the kidney or the urethra that it's largely we're seeing behavioral issues. The other camp that we need to really speak to in the geriatric space is functional incontinence. So functional incontinence is that individuals are getting the urge to go to the bathroom or when they have to toilet, there is either a functional capacity issue where they physically cannot make it to the bathroom, or there's a cognitive issue where they get the urge, but because of some changes to cognition, They either do not act on that urge or they lack insight to have that toileting behavior. When you are working in acute care, we see a lot of this functional incontinence happen in combination with the burdens on our healthcare system, right? We see that individuals have to go to the bathroom, they're waiting a really long time because of our staff shortages, and then we're giving individuals periwicks or external catheters or internal indwelling catheters to prevent any incontinence issues from happening that are a consequence of them being sick. Okay, so when I think about stress incontinence and functional incontinence with aging, super common, a lot of times this is an issue of muscular reserve. If your body is one rep max living, where the demands of your day are at or exceeding your one rep max, your pelvic floor is a set of muscles that is acting no differently, right? If your entire body is experiencing weakness, then your pelvic floor is experiencing weakness too. And what that means is that yes, we want to be very focused in the pelvic floor. We have excellent evidence for pelvic floor muscle training across the age continuum, including older age. And we have to recognize that by increasing the functional capacity of the system, we are going to improve a person's pelvic floor symptoms, which means that you do not have to be a specialist in pelvic health in order to make a significant contribution to a person's incontinence. And this to me lights my soul on fire because incontinence is one of the leading causes of institutionalization in our older adults. It is one of the main reasons. Urinary incontinence, cognition, mobility disability, right? Those are the top three reasons why individuals can no longer be independent in their home. And when I think about the role of PT and OT, the PT OT dream team and rehab in general, we target two out of three of those issues, right? And every single person can target the urinary incontinence piece. And so the first huge message that I want to have with this podcast is that one, every clinician is a geriatric clinician because we are not going to ignore a group of muscles and just say that this is not our scope and we don't know how to handle it because we know how to work with muscles. Two, if you have a person with frailty or sarcopenia on your caseload, we need to screen for pelvic floor dysfunctions because if we are seeing outputs of weakness in the musculoskeletal system in the person that we are working with, we have a higher likelihood that we are going to see something happen with incontinence. And this is extremely important considering that incontinence is a main reason or a big driver for individuals needing institutionalized care or increased help in the home. decreased likelihood that they can age in place. And then let's talk about how we put this fitness forward pelvic approach in, whether you are a pelvic health clinician or not. Okay, when we look at the evidence of pelvic floor dysfunction in an aging population, there's a couple of things that we see. One is that individuals with higher amounts of sedentary behavior are at increased risk for pelvic floor dysfunction at age match. So when you compare a cohort of individuals at the age of 70 or 75, those that are more sedentary are more likely to have incontinence than those that are not. So by getting individuals moving around more, you are going to reduce their risk for urinary incontinence. That is number one. Number two is that individuals who are physically active have reduced rates of significant pelvic floor dysfunction compared to those that don't. And so individuals over the age of 65 who are more active are less likely to have pelvic floor dysfunction. Speaking to the musculoskeletal reserve component of pelvic floor dysfunction and aging. Number three is that for individuals with pelvic organ prolapse, those that are weaker or more sedentary, have higher amounts of sarcopenia and frailty, are more likely to experience subjective symptoms of prolapse. So subjective symptoms of prolapse are feelings like your bladder is coming out, that you feel like there is a ball in the opening of your vagina, or that there are symptoms of bother as if there is a heaviness or a dragging sensation around your pelvis. And this is one that I wanna kind of focus on. So when it comes to pelvic organ prolapse, the combination of an increase in objective range of motion of the vaginal walls in combination with a subjective complaint of bother is the way that we create the diagnosis for pelvic organ prolapse. Objective range of motion changes to the vagina are a sign of aging, right? So we are going to see an increase in vaginal range of motion. We have wrinkles on our skin. We have wrinkles in our pelvis. That is one of our wrinkles. The subjective signs of bother, though, have a discordance between the amount of range of motion that people see and the subjective reports of symptom thresholds in that person. This is true across the lifespan where some people can have a high amount of range of motion and not experience bother or any symptoms at all can be completely asymptomatic and other individuals can have a little bit of range of motion change and experience a high symptom burden. So that range of motion change is like a disc bulge on an MRI, right? We cannot just hold onto that objective range. We have to do that with subjective complaints. What we are seeing is that those with more weakness have higher rates of bother. And this is where I really want to hit on the fitness forward approach. Because if you are a person who is one rep max living, imagine the strain on your pelvis when you are doing a one rep max lift versus you are doing something that is 10 to 15% effort, right? What are you more likely to do when you're one rep maxing? You're more likely to hold your breath, your inner abdominal pressure in your belly comes out. We see a lot more people who are bearing down or straining when it comes to that activity and that repetitive straining can be a risk factor for subjective complaints of prolapse. So if I have an older adult who is 100 max living, then they are straining with activities of daily living, right? They are straining every time they need to exert themselves around their house, which means that they are more likely to experience some of those subjective complaints of something falling out, right? That is a barrier to us being able to load people. So what the heck do we do about it? First, we acknowledge that that straining can be contributing to how a person is feeling within their body, feeling within their pelvis as they go about their day, okay? That's the first thing. The second thing is that we can acknowledge what our body is supposed to do under strain. A lot of our older adults don't realize that they are pushing down into their pelvis when they are doing strainful tasks. Is that even a word? I don't even know. Straining tasks, I guess, is a better way of saying that, across their day. So the way that I will reduce that strain on their pelvis, if they are experiencing these symptoms, is one, I will get them to acknowledge or understand that the pelvic floor should be contracting, not bearing down on effortful tasks. That might mean that I'm gonna ask them to do a tiny Kegel before they stand up. That means that I may ask them to exhale as they are standing up while we are working on getting them stronger so that we reduce the strain on their system and reduce their bothersome symptoms. And the third thing is that I focus on getting them stronger so that they do not strain their pelvis throughout the day. So if I think about how taxing it is on my body when I'm straining, for a person who has had pelvic floor dysfunction, I have had two vaginal births, I understand what that means, but also a person that has a good musculoskeletal reserve, my older adults are edging into that straining a lot faster. than my individuals without that reduction in deficits. So if you are a person who's working in home health, if you are a person who's working in hospital, if you're a person who's working in long-term care or skilled nursing, they are going to oftentimes be straining down, right? And that's why individuals are farting when they get up from a chair. That is your sign that they are bearing down as they are getting up, which means that they are straining on their pelvis, and that may be a risk factor for their symptoms. add in constipation, which is much more common with our individuals in their 70s and 80s because of a combination of decreased drive for hydration, decreases in gut motility, side effects of their medications, and potentially dietary changes, that constipation that straining, that reduction in musculoskeletal reserve is kind of like this trifecta of risk factors for that pelvic burden. That pelvic burden is a huge barrier to our physical activity, right? 50% of individuals with pelvic floor dysfunction reported as a barrier or a reason to stop being physically active. And so if you are having a person who is resistant, maybe let's ask and really deep dive into why, right? So when we are thinking about our fitness forward geriatric clinicians, where I want to finish off this podcast is know that you are already doing pelvic well. Because if you are getting a person to be less sedentary, get them doing movement snacks throughout the day, if you are encouraging physical activity and exercise in your people, and you are teaching proper movement mechanics, including and avoiding of bearing down, when individuals are doing activities of daily living, you know how to teach the brace, which we get you to do in our MMA live with our plank lab, right? That's the foundations of bracing. You are doing pelvic health well, right? Because we see so many of our older adults are struggling with pelvic floor dysfunction and their musculoskeletal reserve is contributing to that risk. If you are stuck with me for MMA Live, you know I end up on a soapbox about pelvic health because it's so, so important that a deconditioned person is a deconditioned pelvic floor and our older adults do not get the care that they need in conservative management of a muscle group that is absolutely within our wheelhouse. And that is also why if you are in MMA level two, we do an entire week on conservative management for the non-internal pelvic floor physical therapist on pelvic floor dysfunction, because it is a huge part and it is not just do Kegels. It is so much more than that. And everybody who is listening to this can get on board and be positively contributing to some of the improvement of those symptoms. And when I think last kind of point to make with saying that you are all doing pelvic well, is that by adding in the screens, increasing the muscular reserve of the system, and speaking a little bit to straining and breathing, I clear up so much pelvic floor dysfunction almost immediately in my practice. It's like my geriatric PT magic trick, right? If I have a person who is having wind or anal incontinence every time they sit up from a chair because their abs are too weak and they're bearing down and holding their breath every time they sit up from a reclined position, then When I teach them to breathe out as they do that, tell them not to bear down and get their abs a little bit stronger, it clears it up almost every time. And it's embarrassing for people, right? They don't want to engage in certain activities because they're afraid, or they pretend that it doesn't happen because it happens to them so often that they just don't acknowledge it anymore, even if they feel it. Oh my gosh, 20 minutes in. Gosh, sorry, Alan. So if you wanna learn and get the rants on the reproductive system, make sure to jump into MMA Live. We are this weekend up in Hendersonville, Tennessee. Julie's up there in Hendersonville and Dustin is in Aspinwall, Pennsylvania. We are going to have incredible groups. They're looking pretty good. The next courses for MMA, because we have sampler, and we have a long weekend. I am up in Bismarck, North Dakota, the 18th, 19th of May, and Jeff Musgrave is in Richmond, Virginia, same weekend. So you either have the chance this weekend to get into MMOA Live or middle of May is your next opportunities. And if you really want to hear me rant and rave about pelvic floor dysfunction, you guys have made it to the end of this podcast. Our level two is starting middle of May, but today's April, I'm losing track of time. And the level one is our prerequisite for that. We are going all the way to the ICE app for all of our MMA courses, starting our next cohort. We are super excited about that. And let me know if you guys have any other questions, because I love blending the Jerry and pelvic worlds together. Thank you so much, Andrea. All right, have a great day, everyone, and we will talk to you all soon.

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