Did you know that MossRehab specializes in therapies for individuals with urinary incontinence and pelvic floor issues? In this episode of MossRehab Conversations: Therapy Edition, Trish Crane, PT, clinical manager MossRehab Plymouth Meeting, and Jenifer Sprague, MPT, Cert MDT, CLT, pelvic floor specialist MossRehab Elkins Park talk about the latest physical therapies to manage urinary incontinence.
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Welcome to MossRehab Conversations: Therapy Edition, a new series where MossRehab clinicians come together to discuss their expertise. In this episode, we join Trish Crane, clinical manager at MossRehab, Plymouth Meeting and faculty member in the Orthopedic PT Residency program. As she speaks with Jen Sprague about the latest advances in treating urinary incontinence with physical therapy. Sprague is a McKenzie certified pelvic floor, and lymphedema specialist with 15 years treating pelvic floor issues.
Jen, thank you so much for joining us and sharing your expertise.
Oh thanks, Trish. Thanks for having me.
I'm particularly excited about discussing the topic of physical therapy management of urinary incontinence, because I hear over and over again from people in the public that they were unaware that physical therapy is an option to manage incontinence. So, can you start with explaining a little bit about what pelvic floor therapy is?
I think that's kind of funny because, usually, when I see a patient for the first time we giggle and then they say, "There's physical therapy for this?"
Actually so, the pelvic floor muscles are just muscles like any other muscle in the body, and they can get weak, and they can also get overused, and get tight. And there's actually specific physical therapy that helps us strengthen the pelvic floor muscles, or relax pelvic floor muscles that are too tight.
And what type of conditions, or diagnoses does a pelvic floor therapist see?
Anybody who has urine leaking, frequency of urine, you have to go to the bathroom every hour, which is actually not normal. I see patients who have pain with intercourse. I treat males, who have leaking after they've had a surgery, or just different episodes, or issues.
As a pelvic floor physical therapist, what does the treatment or examination entail?
Usually, once we get past a little bit of awkwardness of people being in there for pelvic floor issues, we usually do a thorough examination and ask questions. And I sort of akin it to like detective work with somebody. So, looking at their posture, looking at their diet, their exercise, their whole lifestyle, and what their stresses are in a day. And then, may or may not assess the pelvic floor muscles at that point.
So, urinary incontinence is one of the largest diagnoses, the largest population of people seen by a pelvic floor therapist. And two of the most common groupings of the urinary incontinence are stress incontinence and urge incontinence. Talk a little bit about those two types of incontinence, and the differences between them.
It's interesting because the incontinence, it's a huge industry. There's like $600 billion are spent on products. And a lot of times people think, in the general public, "Oh, I went and I got pads for this. So, I'm just correcting the urine leaking that I'm having all the time." And that's actually not really addressing the problem. So, really what physical therapy hopes to do is really strengthen the pelvic floor muscles, so you don't rely on having to use pads anymore, and you can go to a whole movie and sit through a movie without worrying about, "I have to go to the bathroom halfway through." That's really what the aims are for the incontinence piece.
And what is stress incontinence?
Stress incontinence is when you have weak muscles, if you cough, or you sneeze you get some urine leaking.
So, if there's a change in pressure in the pelvic floor, then it leads to a little bit of leakage?
Yep, absolutely.
And what is urge incontinence?
Urge incontinence is when the signals sort of get screwed up and your bladder tells your brain, "Oh my gosh, I have to go to the bathroom. I have to go to the bathroom." And that occurs way more frequently than it should, causing people to go to the bathroom every 30 minutes, or even more frequently sometimes.
And does this happen during the day? At night? Both?
It can happen during the day, it can also happen at night, absolutely.
And can pelvic floor physical therapy assist with managing individuals who lose urinary continence at night, typical bedwetting, if you will?
It can. Yeah so, you can actually train the bladder, and do some behavioral modifications to really help that, absolutely.
One barrier to treatment of pelvic floor conditions, in my opinion, is that many people don't know that physical therapy is an option for these patients. And another barrier is that, oftentimes, our friends, and lots of people that we know have these conditions, so we feel that it's normal because lots of people have it. So, I thought we would play a little game of MythBusters, if you will.
So, I give you a myth and I want you to tell me if it's factual or if it really is just a myth.
Okay.
The first myth is that it's normal to leak urine after you have a child.
It is normal for the first month or two, but after that, it's really abnormal. So, a lot of moms joke about it, "Oh, I leak if I cough, or I jump, or anything like that," but actually it's really not normal.
So, that's something that could potentially be managed using pelvic floor therapy?
Mm-hmm (affirmative).
Great. Okay so, the next myth is that it's normal to have urinary leakage with strenuous exercise.
So yeah, that is really not a normal thing. You should not be leaking urine with lifting muscles. So, again, if you're lifting something heavy, and you're putting more pressure posteriorly, it's just like, uh, my also pet peeve is women doing tons and tons of sit-ups, really hard on the pelvic floor. It overstresses the pelvic floor, and overstretching them.
Our next myth is just a few drops of leakage is not incontinence.
Technically, if you have a few drops of urine that you didn't mean to come out, that is technically incontinent.
All right. Our next myth is that it's normal to wake up to go to the bathroom.
It depends. If you wake up after eight hours of sleep, and you go to the bathroom, absolutely. If your bladder is telling you after laying down for two hours to get up and go to the bathroom, that is not normal. A bladder should be able to hold for a good six to eight hours, unless you're over the age of 75, then one time at night is normal.
Is that dependent upon whether or not you drink prior to going to bed?
If you drink a huge glass of water, or a cup of tea an hour or an hour and a half before bed, you're absolutely going to set yourself up for having to overstretch the bladder, and get up and go to urinate at night.
Our next myth is that urinary incontinence only affects female.
Oh, absolutely not true. I definitely treat males, and they have it after prostatectomies, when they have surgery. Or sometimes males just get some weakness too with age.
Is it more common in females than males in your experience?
I definitely see more females than males, yeah. And the nice thing with males anatomically, they have a longer tube they can stop. Women are less anatomically gifted.
All right. We have a couple more myths here. As a mother of two, every time I went to the OB/GYN for a visit during my pregnancy I was told, "You should do Kegels." Should every pregnant person do Kegels?
Not necessarily. It kind of depends. If you are somebody who has high tone, and you do Kegels, you can really hurt your pelvic floor. In general, I would say yes, Kegels are good during pregnancy, but not always.
What's the normal number of repetitions that we should do? Should it be 1,000 a day?
Oh gosh no. Shoot for like about 40 a day.
Okay. And do they all have to be done at once?
No. And they shouldn't be done at once. You should really stretch them out probably about three times a day, 10 or 15 reps.
Can diet affect incontinence?
Absolutely. And this is really the fun part about it, sometimes it's just making people aware of their habits that can really help them in life. For example, I've treated a person who drank 64 ounces of iced tea a day. So, iced tea, coffee, alcohol are all diuretics. They tend to aggravate the bladder, and they make it work extra. So, if you're drinking a lot of those things it can really aggravate the bladder.
All right, last myth, vaginal weights are necessary to improve urinary leakage.
Generally speaking, I've been doing this since 2004, and I've pretty much never given patients vaginal weights on exception. But no, you absolutely don't necessarily need vaginal weight because those pelvic floor muscles are really just holding your organs up, and they're working against gravity. So, if you can do that, you really don't need vaginal weights.
So, if we are not using vaginal weights, then how do we strengthen the pelvic floor?
Basically, by repetition of Kegels, and different strengthening exercises, working against gravity, and actually holding time. So, if you work on getting those muscles to hold for 10 seconds, then maybe 15 seconds, then 20 seconds they're going to get stronger.
So, I don't know about you, but I don't have the greatest awareness of my pelvic floor muscles and when they're working, or when they're not working. Do you have any innovative techniques, or any technology that you utilize at MossRehab to assist patients with that?
Absolutely. We do biofeedback here, which is really, really helpful. There's two different ways we do it. We use surface electrodes just next to the anus. And you can measure your actual pelvic floor activity on a computer screen, which is very helpful for people. And then, we also have a vaginal probe or a rectal probe that we use, if necessary. But it gives you a lot of information, and tells you whether or not the pelvic floor muscles are overactive, or underactive, and can tell you how long you're able to hold a contraction. It's really just been invaluable.
So, the patient's actually able to see you on the computer when their pelvic floor is contracting?
Absolutely. And this is something that they do not have to take home and do, it's only in the clinic.
Is there an option to be able to take something home?
There is. You can take a sensor home and there's actually products on the market, if you're really interested in it, that we can even recommend.
You've been treating pelvic floor patients for quite some time. And I'm sure you've seen kind of the progression of what we have to offer these patients. What's the latest treatment in the area, and kind of what's new on the horizon?
New on the horizon, I think the coolest thing that I'm seeing with pelvic floor therapy is it's becoming more mainstream. Even in the Oscars, the grab bag, they actually gave pelvic floor little tools, which is cool because I think people are actually thinking about the pelvic floor muscles more. And the cool thing is, as a clinician, I want to see those people right after pregnancy when they have an issue. So, it doesn't take 20 or 30 years to get progressively worse. I want to treat it in the moment so people can be very successful, and avoid having surgeries, or prolapses and issues down the road. So, technology is definitely one piece. And I think we're getting better with education too.
By education is it to just the general public?
Well, no, it's funny though it's actually both because I've had physicians, and nurse practitioners, and nurses that I've treated, who have actually had no idea that there was pelvic floor physical therapy. So, it's interesting. We definitely have a way to go to educate the healthcare professionals and the public.
That was Mackenzie certified pelvic floor and lymphedema specialist, Jen Sprague speaking with Trish Crane, clinical manager at MossRehab Plymouth Meeting on our new multi-part series MossRehab Conversations: Therapy Edition, where MossRehab therapists discuss their expertise in the various clinical fields. Be sure to subscribe, or check back at this website for the next episode. And on the web at mossrehab.com/conversations. You can also listen in as we talk with pioneers in physical medicine from around the globe. Thanks for joining us. I'm Bill Fantini.