Are you aware of all of the non-motor symptoms which affect your patients’ lives?
You a
re most likely familiar with the research on LSVT LOUD® and LSVT BIG® which has shown both short term and long-term improvements in functional communication, mobility, balance and activities of daily living to name a few.
Although the motor symptoms of Parkinson disease (PD) are targeted through the LSVT programs, as LSVT BIG clinicians, we know that we are simultaneously addressing the non-motor symptoms (NMS) as well, which can be barriers to calibration. These NMS include cognitive changes, sensory deficits, anxiety, depression, apathy, fatigue, pain, and sleep.
As an occupational therapist who is not only LSVT BIG Certified, but also a board-certified as a pelvic rehabilitation practitioner and board certified in biofeedback for pelvic muscle dysfunction, having expertise in both has allowed me to comprehensively help manage these motor and non-motor symptoms. Addressing bladder, bowel and sexual dysfunction in my patients with PD has become a standard in my practice due to the high prevalence and significant negative impact these issues have on the quality of life of the person with Parkinson’s, their families, and caregivers. Even though motor symptoms are the most observable in the clinic, the impact of urinary incontinence, inability to easily empty the bowels or challenges with sexual desire, arousal or orgasm, just to name a few, can add to the complexity of dealing with other non-motor symptoms, such as, depression and anxiety, and should not be ignored.
Read on to learn more about how bladder, bowel and sexual dysfunction impacts your patients with PD and what you can do to help!
How Common is Bladder, Bowel and Sexual Health Dysfunction in PD?
Bladder, bowel and sexual health dysfunction are actually very common in PD. Overactive bladder or neurogenic detrusor overactivity, is the most common bladder concern experienced by up to 70% of people with PD. This commonly includes, but is not limited to, urinary urgency, daytime urinary frequency, and nocturia. Constipation, which has been identified as one of the possible prodromal symptoms of PD, is experienced by upwards of 80% of people with PD. Sexual dysfunction prevalence is also very high with 60-80% of both men and women experiencing reduced libido and frequency of sexual intercourse. (Sakakibara, R., et al, 2001; Sakakibara, R., et al, 2011)
A Complex Issue
The profound complexity of the nervous system can make treatment of these particular non-motor symptoms a challenging feat. Let’s review three parts of the nervous system that play a role in control of our bladder, bowel, and sexual function: sympathetic, parasympathetic, and somatic nervous systems. The first two together are called the autonomic or involuntary nervous system, and the third is the somatic or voluntary nervous system.
In short summary, our sympathetic nervous system helps with storage of urine and stool and facilitates ejaculation. The parasympathetic nervous system facilitates urination, evacuation of stool, and with engorgement of the sexual tissues. The somatic nervous system plays a role in voluntary control of the bladder and bowel for social appropriateness and assists in maintaining engorgement of the sexual tissues while also enhancing the strength of orgasm. The availability of dopamine plays a role in these complex functions running smoothly.
On the other hand, when we consider the voluntary somatic nervous system, in LSVT BIG we are thinking about the restoration of normal amplitude of movement in the limb motor system. Now let’s expand that thought to the muscles making up the pelvic floor. When a person with PD experiences a urinary urge, what needs to occur in the pelvic region? If the pelvic floor is not voluntarily tightened in an isolated fashion and with enough effort to produce sufficient amplitude of motor output, the urge may not be able to be suppressed and urinary incontinence may occur.
A Sensory Motor Mismatch of the Pelvic Floor?
Does the person with PD sense where to contract and the level of contraction they need to overcome the strength of the urge they experience? The sensorimotor deficit visually observed as degradation in movement amplitude in the limb motor system is also suspect in the pelvic floor. Additionally, consider the lengthening/opening of the pelvic floor that must occur for emptying the bowels. Adequate amplitude of the descent of the pelvic floor and proper coordination with the abdomen to do so may also not be sensed. Further, strengthening of the pelvic floor is an effective technique for improved sexual health functioning, but may also be challenged by impaired sensorimotor feedback. Treatment of this sensory motor mismatch in the pelvic floor requires specialized expertise and feedback from an OT or PT who treats pelvic floor dysfunction. Naturally, having an awareness of the underlying sensory motor mismatch which often occurs in PD is important for the treating therapist.
Can LSVT BIG Help?
While LSVT BIG itself is not used to directly treat issues related to bladder, bowel and sexual dysfunction, we do know that exercise in itself can have a positive impact on symptoms affecting pelvic health related issues, such as, fine motor coordination for clothing and peri care management for toileting, balance and functional mobility for getting to and from the restroom at home and in the community efficiently and safely, and flexibility for bed mobility and positioning for sexual intercourse, just to name a few.
Furthermore, because we form such a close relationship with our patients over a month of intensive treatment, we are perfectly positioned to notice bathroom habits, listen for concerns related to these issues, ask sensitive questions, screen for additional medical and therapy treatment needs and provide some basic education on the interrelationships of bladder, bowel, and sexual health. If they are open to further evaluation and treatment, we can also help them to navigate the complex world of medicine, getting them to the right people who can help them.
What specifically can you do to help if you are not a pelvic rehabilitation specialist?
1. Gain awareness of these bladder, bowel and sexual issues as they occur in PD.
Here are some good sites where you learn more about bladder, bowel and sexual dysfunction in PD:
- Foxfeed Blog Podcast: Urinary Problems in Parkinson’s Disease
- Foxfeed Blog Podcast: Constipation and Parkinson’s
- Third Thursday Webinars on Parkinson’s Research
- Sexual and Reproductive Health with Parkinson’s
- Intimacy Issues and Parkinson’s Disease 101
- Parkinson’s and Sex: Diminished Sexual Function, Hypersexuality and other sexual effects of Parkinson’s
2. Learn how to listen and ask your patient the right questions which might open the door to conversation.
Is your patient leaving the session often for bathroom breaks?
Ask them if they notice if particular beverages affect their bladder.
Is your patient often fatigued and reports not sleeping well at night?
Ask them if their bladder wakes them often at night.
Does your patient avoid drinking water during exercise?
This may be a small clue they are restricting fluids to avoid bladder overactivity (also increasing risk of constipation).
Is your patient often late for sessions and they mention bathroom issues as an excuse?
Don’t be afraid to ask what they are experiencing.
Utilize subtle hints your patient gives to expand conversation, for example, if your patient says they no longer sleep in the same bed due to fear of sleep disruption of their partner, ask them if this a frustration for their relationship.
Actively raise the subject, for example, saying “You may be unaware, but Parkinson disease may affect your sexual life. There are specialists that can treat sexual problems and I can help you find the right person.”
3. Seek out therapists who specializes in treatment of bladder, bowel and sexual dysfunction issues. Here is how you can find them:
- Pelvic Rehab
- Biofeedback Certification International Alliance
- American Board of Physical Therapists (ABPT)
- CAPP Certificate Program
4. Screen for issues which should be mentioned to the doctor such as:
- Signs of a possible UTI: frequent urination with burning, odor, cloudiness; new onset or worsening of cognition/confusion
- New onset severe abdominal pain which may be a sign of bowel obstruction
- No bowel movement in over 7-10 days
5. What tips and resources you can give to a patient related to bladder, bowel and sexual health?
-
Constipation and Other Gastrointestinal Problems in Parkinson’s Disease
- Carlton, L. (1994). Sex, love, and chronic illness. National Parkinson Foundation.
Are you interested in gaining expertise so you can treat these issues before or after LSVT BIG?
If you are currently practicing in the area of pelvic rehabilitation but have not expanded your referral base to your neurologists and movement disorder specialists and/or need advanced knowledge about pelvic health restoration in Parkinson disease, you may want to consider attending Neurologic Conditions and Pelvic Floor Rehab through the Herman and Wallace Rehabilitation Institute. I am the author and instructor of this new course and would love to share more of my knowledge with you!
Is pelvic rehabilitation new to you? Here are some basic courses I can recommend which will start to build your foundation.
Summary
Bladder, bowel and sexual dysfunction issues are highly prevalent in PD and impact our patients’ quality of life. While they are not something directly treated during LSVT BIG, because we get to know our patients so well over the course of a month of LSVT BIG, we are in a unique position to listen and look for clues, offer basic education and tips, and help them navigate the complex medical world to get the treatment they need to address these issues head on.
References:
Sakakibara, R., Kishi, M., Ogawa, E., Tateno, F., Uchiyama, T., Yamamoto, T., & Yamanishi, T. (2011). Bladder, bowel, and sexual dysfunction in Parkinson’s disease. Parkinson’s Disease, 2011.
Sakakibara, R., Shinotoh, H., Uchiyama, T., Sakuma, M., Kashiwado, M., Yoshiyama, M., & Hattori, T. (2001). Questionnaire-based assessment of pelvic organ dysfunction in Parkinson’s disease. Autonomic Neuroscience, 92(1-2), 76-85.
