Article Archive
November/December 2022

Easy Does It
By Richard Sabel, MA, MPH, OTR, GCFP; Alison Lin, MSOT, OTR/L; Casey Caruso, MS, OTR/L; Ilana Forchheimer, MS, OTR/L; and Kerri Percoco, MS, OTR/L
Today’s Geriatric Medicine
Vol. 15 No. 6 P. 14

A Zoom Group Program for Older Adults With Urinary Incontinence

Patients and providers often avoid conversations about urinary incontinence (UI). But given the millions of older adults suffering from the condition, the time has come for health professionals to have open, frank discussions with their clients. We need to let people know they are not alone in their suffering and that simple, straightforward solutions exist for most individuals.

This article provides an overview of UI, clarifies its broad impact on patients’ ability to engage in meaningful activities, and highlights the efficacy of a cost-effective Zoom group program for older adults suffering from UI.

Facts About UI
UI is defined as the involuntary loss of urine. In the United States, about 10 million individuals have been diagnosed with UI. It’s estimated that 25 million individuals have experienced UI at least once,1 and more women than men experience it.2

Research shows that the frequency and severity of UI increase with age. For men, the prevalence increases from 5% for those aged 19 to 44 to 21% for men older than 65.3 For nonpregnant women under 35, UI increases from 3% to more than 50% for women older than 65.4 Therefore, as the number of older adults grows, it can be expected that the prevalence of UI will also increase.

Additionally, many risk factors such as pregnancy, birth-related injuries, hysterectomies, hormonal-related factors, prostate issues, family history, age-related changes, infections of the urinary tract, obesity, caffeine intake, smoking, a sedentary lifestyle, trauma, and improper core strengthening can increase the likelihood of experiencing UI.5-9

Types of UI
UI may be categorized into four types: stress, urge, mixed, and functional.10-12 The most prevalent type is stress incontinence, which is defined as leakage of urine caused by increased intra-abdominal pressure during activities such as coughing, sneezing, or bending. Urge incontinence is characterized by a sudden urgency to void and is associated with an overactive bladder due to irregular activity of the detrusor muscle. Mixed incontinence is described as a combination of stress and urge incontinence.10,11 Functional incontinence occurs when physical, cognitive, or environmental factors make it difficult for an individual to use the bathroom.12

Impact of UI
The impact of UI on quality of life is pervasive. It affects activities of daily living, such as toileting, rest, sleep, work, sexual activity, and leisure.13 It’s not uncommon for people to withdraw from social engagements and other meaningful activities due to embarrassment and the fear of leaking in public.14-15 This retreat can lead to a more sedentary lifestyle—a key risk factor for diseases such as high blood pressure, obesity, type 2 diabetes mellitus, and mortality,17-20 all of which not only diminish quality of life but also can increase the likelihood of depression and other psychological problems.21,22

UI is also costly to individuals and to the United States health care system. In 1999, expenses related to pelvic floor issues were approximately $12 billion annually; in 2007, this number increased to $66 billion.14

Treatment
Traditionally, UI treatment includes pelvic floor muscle training, biofeedback, internal manual therapies, surgeries, and electrical stimulation. In addition to these physical-based interventions, a broader approach, which addresses behavioral and environmental factors, facilitates better outcomes.

Behavioral factors are the actions individuals perform that can influence the occurrence and severity of UI symptoms. They can include an individual’s thoughts, habits, and patterns of daily living. For example, individuals may minimize their fluid intake to avoid using the bathroom, yet this can cause dehydration. Individuals may also try to minimize the risk of experiencing leakage by frequently using the bathroom “just in case.” Unfortunately, this technique can train the bladder to contract before it’s full, leading to the development of urge incontinence.

Environmental factors that may influence UI symptoms include one’s home layout, social support, and engagement in the community. Simple interventions such as ensuring the pathway between the bedroom and bathroom is clear and well-lit can minimize the risk of a fall. Choosing clothing with easy-to-release fasteners can be very helpful for people suffering from urge incontinence.

Easy Does It — A More Holistic Approach to Treating UI
Easy Does It was developed as a group program to address the physical, behavioral, and environmental factors for individuals experiencing UI and other pelvic health issues. Eight 90-minute Zoom classes were led by a licensed occupational therapist, sessions consisting of gentle exercises in sitting and standing that engaged the pelvic floor muscles. Participants also learned how to use these muscles in everyday movements, such as bending, squatting, lifting, and standing from a chair. Additionally, education on behavioral and environmental factors was provided.

The program started with breathing. Most people don’t know the pelvic floor muscles are also called the pelvic diaphragm. When we breathe, the respiratory and pelvic floor diaphragms move together—a process known as the dance of the diaphragms. Helping participants sense and feel this dance is the foundation of the program. We breathe in and out more than 20,000 times per day. Having the pelvic floor muscles shorten and lengthen throughout the day is key to maintaining their flexibility and strength. Tight or lax pelvic floor muscles are weak and can lead to pelvic pain and UI. The breathing exercise addresses both conditions. Called the Pelvic Breath, it’s used with all the program’s exercises.

Additionally, the pelvic floor muscles can be viewed as “the floor of the core.” The core is comprised of the respiratory diaphragm at the top, abdominals in the front, multifidus muscles in the back, and the pelvic floor muscles at the bottom. The core muscles play a significant role in breathing, spinal stability, posture, balance, and continence. Seen in this context, UI due to weakness in the pelvic floor muscles can also be viewed as core dysfunction, which can negatively affect these key functions. Therefore, improving the coordination of core muscles is a key step in treating UI.

Education is important as many people believe core strengthening is specific to the abdominals. However, this focus can create an imbalance and puts excessive pressure on the pelvic floor and respiratory diaphragms. Imagine squeezing a tube of toothpaste from the middle. The toothpaste would be forced to go toward the top or bottom of the tube. This is what happens when the abdominals are overdeveloped; it creates a “corset” that restricts movement of the “diaphragms,” which promotes chest breathing and can contribute to UI and other types of pelvic health issues.

You may wonder why not just teach Kegels—Kegel exercises, often referred to as the gold standard in UI treatment, only focus on the urogenital (the front) portion of the pelvic floor, and educational handouts are often provided without proper instruction. Done incorrectly, Kegal exercises can create imbalances and restrictions in the pelvic floor muscles as people often use too much effort and contract the back portion of the pelvic floor (levator ani muscles) around the anus that are easier to access. Interventions that address breath and the coordination among the core muscles not only strengthen and balance the pelvic floor muscles but also provide additional benefits, such as promoting efficient breathing, improving core strength, balance, and posture.

To promote the generalization of learning, the last phase of the program focuses on using the pelvic floor muscles while transitioning from sitting to standing, bending, and lifting items from the floor. This context helps participants apply what was learned in the sessions to everyday activities. Put another way, in addition to addressing UI, the functional segment helps participants move with more comfort, ease, and stability throughout the day. Moreover, participants valued the connection to function and felt it made the process more fun and engaging.

Impact of the Easy Does It Program
Participants completed the King’s Health Questionnaire (KHQ) before and after the program. The KHQ is a standardized tool used to assess UI symptom severity and how UI impacts quality of life (ie, household tasks, social life, partner relationship, sex life, etc). After completing the program, all participants demonstrated improvements on the KHQ in both domains.

Additionally, we felt it was important for each participant before the beginning of the program to identify two meaningful activities that were affected by UI and reflect on their ability to perform these activities through self-ratings. A 1 to 10 rating scale was used to assess two factors, their performance of each activity, and their satisfaction with the performance of each activity. Going for walks, sleeping, playing with grandchildren, socializing, and sexual activity were some of the activities selected. Participants completed performance and satisfaction ratings for the same two activities at the conclusion of the program. After eight weeks, the average perceived performance and satisfaction increased for all participants.

Lastly, weekly surveys were administered to collect information on changes in symptoms and how frequency of practice affected progress in the program. As weeks progressed, participants indicated decreased pain and fewer UI episodes. Interestingly, participants who regularly practiced outside of program sessions had greater improvements in scores on the KHQ compared to participants who reported little or no practice.

Future of UI Treatment
Individuals with UI often feel embarrassed by their condition, which leads to under-reporting.14,19 Therefore, if health care professionals do not explicitly ask about UI, the topic may not be addressed. Group-structured interventions, like Easy Does It, may be less intimidating than meeting one-on-one with a physician or therapist for some individuals. Additionally, a group setting creates an environment where individuals with similar experiences can relate to one another and feel more supported. A few participants noted that being a part of a group made them less self-conscious; it also made it easier to confide in and support fellow members. Finally, positive results were achieved via a Zoom program. This opens the door to a cost-effective way of reaching people who are homebound or do not have easy access to a group setting. It also allows for more flexibility in scheduling. Let’s start the conversation.

— Richard Sabel, MA, MPH, OTR, GCFP, is a clinical assistant professor at SUNY Downstate Medical Center’s Occupational Therapy Program and the educational director of East West Rehab.

— Alison Lin, MSOT, OTR/L, has a BS in psychology from Macaulay Honors College at City College and a master’s in occupational therapy from SUNY Downstate Health Sciences University. She’s an occupational therapist at a nonprofit preschool, working with children through play-based motor activities to address delays in fine and gross motor, self-care, and sensory integration to improve overall participation in their environments.

— Casey Caruso, MS, OTR/L, has a BA in psychology from Binghamton University and a master’s in occupational therapy from SUNY Downstate’s Health Sciences University. She is an occupational therapist at an outpatient hospital facility that specializes in neurological rehabilitation.

— Ilana Forchheimer, MS, OTR/L, has a BS in human development from Binghamton University and a master’s in occupational therapy from SUNY Downstate’s Health Sciences University. She’s an occupational therapist at a NYC-based nonprofit organization that helps homeless and low-income individuals who often have mental health diagnoses and substance use disorder gain independence and increase their quality of life.

— Kerri Percoco, MS, OTR/L, has a BA in psychology from Binghamtom University and a master’s in occupational therapy from SUNY Downstate’s Health Sciences University. She’s an occupational therapist at a children’s hospital in the NYC area, providing outpatient therapy to children and young adults with complex medical and developmental needs.

 

References
1. Demaagd GA, Davenport TC. Management of urinary incontinence. P T. 2012;37(6):345-361H.

2. Angelini K. Pelvic floor muscle training to manage overactive bladder and urinary incontinence. Nurs Womens Health. 2017;21(1):51-57.

3. Urinary incontinence in men. UpToDate website. https://www.uptodate.com/contents/urinary-incontinence-in-men. Accessed April 6, 2022.

4. Evaluation of females with urinary incontinence. UpToDate website. https://www.uptodate.com/contents/evaluation-of-females-with-urinary-incontinence. Accessed April 12, 2022.

5. Casey EK, Temme K. Pelvic floor muscle function and urinary incontinence in the female athlete. Phys Sportsmed. 2017;45(4): 399-407.

6. Carpenter DA, Visovsky C. Stress urinary incontinence: a review of treatment options. AORN J. 2010;91(4):471-481.

7. Ramalingam K, Monga A. Obesity and pelvic floor dysfunction. Best Pract Res Clin Obstet Gynaecol. 2015;29(4):541-547.

8. Sigurdardottir T, Steingrimsdottir T, Geirsson RT, Halldorsson TI, Aspelund T, Bø K. Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An accessor-blinded randomized controlled trial. Am J Obstet Gynecol. 2020;222(3):247.e1-247.e8.

9. Wood LN, Anger JT. Urinary incontinence in women. BMJ. 2014;349:g4531.

10. Ghaderi F, Oskouei AE. Physiotherapy for women with stress urinary incontinence: a review article. J Phys Ther Sci. 2014;26(9):1493-1499.

11. Kołodyńska G, Zalewski M, Rożek-Piechura K. Urinary incontinence in postmenopausal women — causes, symptoms, treatment. Prz Menopauzalny. 2019;18(1):46-50.

12. Urinary incontinence. MayoClinic website. https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/symptoms-causes/syc-20352808. Accessed April 30, 2022.

13. American Occupational Therapy Association. Occupational therapy practice framework: domain and process-fourth edition. Am J Occup Ther. 2020;74(Suppl 2):7412410010p1-7412410010p87.

14. Chen CCG, Cox JT, Yuan C, Thomaier L, Dutta S. Knowledge of pelvic floor disorders in women seeking primary care: a cross-sectional study. BMC Fam Pract. 2019;20(1):70.

15. Cheng S, Lin D, Hu T, et al. Association of urinary incontinence and depression or anxiety: a meta-analysis. J Int Med Res. 2020;48(6):300060520931348.

16. Krüger AP, Luz SC, Virtuoso JF. Home exercises for pelvic floor in continent women one year after physical therapy treatment for urinary incontinence: an observational study. Rev Bras Fisioter. 2011;15(5):351-356.

17. Bø K. Urinary incontinence, pelvic floor dysfunction, exercise, and sport. Sports Med. 2004;34(7):451-462.

18. Diaz KM, Howard VJ, Hutto B. Patterns of sedentary behavior and mortality in US middle-aged and older adults: a national cohort study. Ann Int Med. 2017;167(7):465-475.

19. Minassian VA, Yan X, Lichtenfeld MJ, Sun H, Stewart WF. Predictors of care seeking in women with urinary incontinence. Neurourol Urodyn. 2012;31(4):470-474.

20. Teychenne M, Costigan SA, Parker K. The association between sedentary behaviour and risk of anxiety: a systematic review. BMC Public Health. 2015;15:513.

21. Kao HT, Hayter M, Hinchliff S, Tsai CH, Hsu MT. Experience of pelvic floor muscle exercises among women in Taiwan: a qualitative study of improvement in urinary incontinence and sexuality. J Clin Nurs. 2015;24(13-14):1985-1994.

22. Murray AS. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Research in Nursing & Health. 2019;42(3):234-235.