Chronic Disease Management 3: Urinary Incontinence – Part 2

Alright, so I left you with a pretty serious cliffhanger on that last post. Here is the big ending! This is going to go pretty deep into the BASICS of management techniques for urinary incontinence. Like I keep saying, I’m not a pelvic floor therapist, but I do know enough about the basics that I can help you out and get you started. In Part 1 of this post, we discussed MANY of the lifestyle changes that need to happen to reduce or resolve urinary incontinence, but in this post, we are going to talk about the exercises! Remember, these posts are discussing management of urinary incontinence in all populations, but specifically in the presence of other chronic diseases. You can read much more about that in Part 1. Here is a little review…

I was speaking with a colleague of mine who also does a fair amount of chronic disease management and critical care work as a Physical Therapist. We were discussing heart failure management, the incidence of incontinence and urinary tract infection, and the effects these things have on our patients. We came up with this saying, “If you drink too much water, you’ll die. If you don’t drink enough water, you’ll die.” As morbid as that sounds, it’s all about finding the healthy balance.

In the case of heart failure, you’ll tend to find that less water is better (due to fluid limitations) but that patients still need to meet a minimum amount in order to function. Many of these patients ALSO develop urinary incontinence, either as a secondary effect of their heart failure medications and pathophysiology, or as a diagnosis due to many other possible causes. Finding their individual healthy balance can be really tough, but they definitely can’t do it alone. They need your education in the importance of water for the proper function of the cardiopulmonovasculorenourinary system. Ha!

Photo by Tim Mossholder on Pexels.com

Patients who have COPD also have a very high incidence of urinary incontinence which is thought to be linked to chronic coughing and structural changes in their chest which lead to changes in the length-tension relationship of the diaphragm and altered breathing patterns. If you read the post on Intra-Abdominal Pressure and Part 1 of Urinary Incontinence Management, you’ll understand that these relationships play a large role in pelvic floor function, bladder contractility, and incontinence management. Feel free to check out all the other linked posts to put that one together for yourself.

Pelvic Floor Strengthening and Managing Bladder Contractility

I’ll start off by just clearly stating a reminder here: NOT ALL PATIENTS NEED KEGELS. I know, we hear about Kegels all the time. They are huge part of incontinence management because stress incontinence or mixed incontinence which is at least partially stress incontinence is a large proportion of cases. If your patient is reporting symptoms of overflow incontinence, you may not want to use Kegels for management because they don’t need more tightening! I continue to not claim to be an expert, so when in doubt, consult your local pelvic floor therapist.


Time for an Anatomy Lesson: Two Types of Kegels

The Quick Flick and the Long Hold are the two main types of Kegels exercises I use with my patients. I use them both and for different reasons, so I’ll take you through the specifics. Quick Flicks are also referred to as “knacks”, so you will see both terms used here. It’s important to remember that several different muscle fiber types exist in the muscles of the pelvic floor and all must be addressed to adequately increase strength. Anatomy lesson: We are talking about the levator ani muscle, which provides the “sling” support for the pelvic organs. This muscle, in addition to several smaller hip and pelvis muscles, makes up the pelvic floor. Coccygeous is the small band of muscle just posterior in this image, and also helps to support the pelvic organs.

The Levator Ani, which has three parts with different functions, is going to be the focus of the morphological information I provide. Going back to your basics, you have type 1 (slow-twitch) and type 2 (fast-twitch) fibers present in the muscles of the pelvic floor. These fiber types both decrease in number and size with age. Research shows us that more than 50% of women CANNOT voluntarily contract their pelvic floor muscles, and personal experience is that a far greater a number of men also cannot. People NEED to be trained.

The Tiny Pebble

Here goes my crazy. I get some serious looks for this one, but it WORKS!!! The way the levator ani contracts is similar to the diaphragm. When it contracts, it pulls upward in to the body. When you teach someone how to activate and contract this muscle, you need to ensure they are performing the correct motion. A very effective way to do this is to use the “Tiny Pebble” explanation. You ask your patient to pretend that there is a tiny pebble at the opening of their anus. To perform a pelvic floor contraction, they want to grab the tiny pebble with their anus and then attempt to pull it up inside. How long they do this for will be determined by the type of exercise you are asking them to do. Here is what I mean:

The Quick Flick: How-To and Why

Quick flicks are fast contractions of the pelvic floor. These address the type 2 muscle fibers. Increasing the presence and function of type 2 muscles fibers BY ITSELF can significantly reduce the presence and risk of stress incontinence.

You will ask your patient to grab the pebble 5 times in a row, and put it back down between each one. These should be somewhat fast but that will depend on your patient’s skill level.

Quick flicks, or knacks, are really useful for two things:

  1. Performing a quick flick just prior to an increase in intra-abdominal pressure, like a cough or sneeze, can give the pelvic floor a bit more support to prevent leakage. This is the primary usage of knacks.
  2. The other function of quick flicks is neurological. Say you are walking home and are about 5 minutes from your door. You know you have to go to the bathroom pretty bad because your bladder is sending you all kinds of signals telling you so. If you perform a few sets of quick flicks, you can silence those alarms temporarily until you can get home to use the bathroom, essentially preventing function incontinence.

That second one can be really useful for our patients who need to get up out of bed in the middle of the night to use the bathroom, but have a long walk, move slowly, or need to make several adjustments and preparations before going. You can just buy a little bit of time to reduce the rushing, make the trip safer, and reduce the fall risk.

The Long Holds: How-To and Why

Long Holds address type 1 muscle fibers (the slow-twitch fibers). Increasing the size and number of these muscle fibers can significantly improve pelvic organ support and be helpful for different types of overflow incontinence that may be due to organ prolapse. However, it can also be really useful for long-term strengthening programs and endurance training. Sometimes we are further than 5 minutes from home and still have to wait.

To instruct your patient in long holds, ask them to grab the tiny pebble, pull it up inside, and hold it there. I typically start with 5 second holds and build from there. I have them do one 5-second hold at a time.

The “why” of this one I feel like is pretty obvious but it’s basically endurance. You need to be able to support your pelvic organs all day and you need to control your urine flow all day. This may take some time to achieve and there are all different ways to go about this training. I like to have people in the hospital or at home perform their pelvic floor exercises every time a commercial comes on the TV. That gets a lot of sets and reps in!

The Bigger Picture

Planning out your sets and reps shouldn’t be any different than when you are training any other muscle group. If you are using the Oddvar-Holten curve to prescribe your sets and reps, and you want to focus on strengthening, you may want to do fewer reps per set than if you were working on endurance training with longer sets of more reps. You can’t really calculate a 1-Rep Max other than the weight of the internal organs, so using body weight is about the closest you’re going to get. Just a different way to apply the basics of what you already know, right?

But that’s not the whole thing. I talked a lot about intra-abdominal pressure regulation in relationship to the pelvic floor and my instruction in pelvic floor exercises is not complete without including instructions on how to properly BREATHE during these exercises. I will want you now, when your patients perform these, they will hold their breath, just like every other type of exercise we have patients do. They may also stick their tongue out or raise their shoulders or eyebrows with the muscle contractions. I typically end up doing the eyebrow thing, too, when I’m teaching it… It makes it a bit more entertaining. But you have to correct the breathing part! When you put it all together, your instructions to your patient go like this:

01


Quick Flicks

Breathe IN, Breathe OUT
As you breathe out, reach out and grab the pebble and let it go
Count out loud for each time, “1, 2, 3, 4, 5”
Relax & Repeat

02


Long Holds

Breathe IN, Breathe OUT
As you breathe out, reach out, grab the pebble, and pull it up inside… and HOLD!
Count out loud for a five-second hold, “1, 2, 3, 4, 5”
Relax & Repeat

The counting out loud part of this is crucial. If they aren’t counting out loud, they are probably holding their breath. If they are counting out loud, you know they are breathing out! Like I mentioned earlier, you will inevitably get many people who hold their breath during these exercises. I like to remind them that these particular muscles are NOT breathing muscles. I know that is a bit simplistic, but it makes them laugh a bit and then I know they are breathing.

BONUS: Internal Exam NOT Required

When you are instructing patients in these techniques, research has shown that verbal instruction alone is more than sufficient to produce the ability to contract the pelvic floor musculature.


Protecting the Pelvic Floor

You may work with a population of patients who are young, highly athletic, healthy, and deny any urinary incontinence or other pelvic floor issues. That is so great! But, let’s keep it that way, shall we? The BEST way to treat a chronic disease is to prevent it from happening in the first place! It is important to remember that the pelvic floor is a set of muscles, tissues, bones, and joints that need to be cared for, well used, and protected, just like any other body system. You need to take in to consideration patients who do high-impact activity and/or high-load lifting. Their intra-abdominal pressure regulation is CRUCIAL to protecting that pelvic floor. Read more about that in the post specific to intra-abdominal pressure. But pregnant women also need to know some tips on protecting their pelvic floor before, during, and after birth so that they can have minimal issues throughout. Obviously, there is a tiny-space occupying person that is GOING to cause some strain, so we have to work on how to manage that strain.

High Impact & High Load Athletes

High impact athletes, like runners, gymnasts, and cheerleaders, can find some pretty interesting ways to force their body to achieve the high level tasks the want to achieve. That doesn’t necessarily mean they are using their body the right way to achieve them. Runners may need help with regulating their breathing and maintaining the strength of their pelvic floor muscles to prevent leakage on the initial contact phase of their running gait. Gymnasts and cheerleaders may find that they can stabilize their body in many crazy ways, but can also be fully capable of stabilizing with your shoulder complexes or their glutes and still have minimal core activation. This combination CAN lead to reduced pelvic floor muscle activation and result in stress urinary incontinence. If that is the case, you may find you have to reprogram their trunk stability techniques to include pelvic floor and core.

Photo by Frans Van Heerden on Pexels.com

For high-load athletes, like power lifters and functional fitness participants (F45, Crossfit, etc), you are really going to have to work with them on proper form, training certain muscle groups, and regulating intra-abdominal pressures. They will probably need to do some specific pelvic floor training to know how to regulate the pressures when they need to without increasing strain on the pelvic floor musculature.

You may also work with a different kind of athlete: The manual laborer. These workers may have to lift heavy loads with or without assistance. They may be utilizing all types of strategies to achieve these work loads, but you may also find that many of them are presenting with impairments to their pelvic floor. These may or may not be related to incontinence. You may see a higher rate of abdominal or inguinal hernias, piriformis syndrome, glute atrophy, or any number of other conditions that impact the pelvic floor due to altered length-tension relationships or unregulated intra-abdominal pressure. These may also include prolapses, as intra-abdominal pressure can result in all different types of this condition. Prevention is the key. Strengthen the pelvic floor, train better body mechanics, teach lifting safety, and regulate intra-abdominal pressure.

Pregnancy, Labor, and Post-Partum

This section could be a whole other post, but, like I keep saying, I’m no expert here. What I can tell you is that pregnant women have to pee, a lot. It’s a function of a growing baby taking up space and physically placing pressure on the bladder and other organs within the intra-abdominal space. Not all women will experience incontinence with pregnancy, but many will. We can’t resolve that for the most part, but we can improve it. Lots of water and lots of bathroom breaks are crucial for incontinence management for pregnant women, but this isn’t always achievable due to work and life demands. So, do the best you can with the schedule.

Strengthening that pelvic floor and training knacks will not only help patients manage incontinence, but prepare them for birth. Think about a patient who needs a total knee replacement but has weak quads… You wouldn’t expect them to have a stellar rehab from that knee replacement unless they did some pre-habilitation first to increase quad strength and activation. The same goes for birth. Strengthening the pelvic floor prior to birth can shorten and ease the recovery afterward. Good pelvic floor activation and control can help post-partum women regain control of their incontinence before it becomes a bigger issue. Remember how we talked about the importance of length-tension relationships and breathing with pelvic floor functoin? In the case of cesarean section (C-section) managing intra-abdominal pressure and reducing the work of the pelvic floor can be crucial. Again, not an expert here, so get them to a pelvic floor therapist ASAP!


Most of all, if you have incontinence, if your friend does, or your mom does, or your neighbor does, or your gym buddy does, tell them there is help that doesn’t involve surgery or medication. Tell them about pelvic floor PT. Network with the pelvic floor PT’s in your area. These PT’s are amazing! Give out their cards. Make it a normal thing to talk about. Your friends, family, and patients will thank you.

Do you have a favorite Pelvic Floor PT in your area? We can all use a bigger network! Give them a shout out in the comments!

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More about how Physical Therapists Manage Chronic Disease…

Dehydration

Gosh, this is a fine line… Especially in the patients I regularly see. A colleague and I often say, “If you have any more water, you’ll die. If you don’t have any more water, you’ll die.” This is actually a frequent education topic that I cover with patients. Scary? Yes, but true. So, why isContinue reading “Dehydration”

Spilling the Box of Pearls: All the Tips on Supplemental Oxygen Management

In my recent post on COPD management, I mentioned that there are some really important parts of supplemental oxygen management that you need to be aware of and consider in your practice. If you are assisting patients who utilize supplemental oxygen regularly, you need to keep these things in mind. You also may be workingContinue reading “Spilling the Box of Pearls: All the Tips on Supplemental Oxygen Management”

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References

Ayeleke, R. O., Hay-Smith, E. J., & Omar, M. I. (2015). Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women. The Cochrane database of systematic reviews2015(11), CD010551. https://doi.org/10.1002/14651858.CD010551.pub3

Bush, H. M., Pagorek, S., Kuperstein, J., Guo, J., Ballert, K. N., & Crofford, L. J. (2013). The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-Sectional Study. Journal of women’s health physical therapy37(1), 11–18. https://doi.org/10.1097/JWH.0b013e31828c1ab3

Carvalho, N., Fustinoni, S., Abolhassani, N. et al. Impact of urine and mixed incontinence on long-term care preference: a vignette-survey study of community-dwelling older adults. BMC Geriatr 20, 69 (2020). https://doi.org/10.1186/s12877-020-1439-x

Fitz, F. F., Paladini, L. M., Ferreira, L. A., Gimenez, M. M., Bortolini, M., & Castro, R. A. (2020). Ability to contract the pelvic floor muscles and association with muscle function in incontinent women. International urogynecology journal31(11), 2337–2344. https://doi.org/10.1007/s00192-020-04469-0

Koelbl, H., Strassegger, H., Riss, P. A., & Gruber, H. (1989). Morphologic and functional aspects of pelvic floor muscles in patients with pelvic relaxation and genuine stress incontinence. Obstetrics and gynecology74(5), 789–795.

Kuchel, G. A. and DuBeau, C. E. (2009). Urinary Incontinence in the Elderly in Geriatric Nephrology. American Society of Nephrology. Retrieved from https://www.asn-online.org/education/distancelearning/curricula/geriatrics/Chapter30.pdf

Mayo Clinic. (2020). Bladder Control: Lifestyle strategies ease problems. Retrieved from https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/bladder-control-problem/art-20046597

Nuotio M, Tammela TL, Luukkaala T, Jylhä M. Predictors of institutionalization in an older population during a 13-year period: the effect of urge incontinence. J Gerontol A Biol Sci Med Sci. 2003 Aug;58(8):756-62. doi: 10.1093/gerona/58.8.m756. PMID: 12902536.

Simmering, J. E., Tang, F., Cavanaugh, J. E., Polgreen, L. A., & Polgreen, P. M. (2017). The Increase in Hospitalizations for Urinary Tract Infections and the Associated Costs in the United States, 1998-2011. Open forum infectious diseases4(1), ofw281. https://doi.org/10.1093/ofid/ofw281

Welk B, Baverstock R. Is there a link between back pain and urinary symptoms? Neurourol Urodyn. 2020 Feb;39(2):523-532. doi: 10.1002/nau.24269. Epub 2020 Jan 3. PMID: 31899561.

Zilberberg MD, Shorr AF. Secular trends in gram-negative resistance among urinary tract infection hospitalizations in the United States, 2000–2009. Infect Control Hosp Epidemiol 2013; 34: 940–6.

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Chronic Disease Part 3: Urinary Incontinence – Part 1

All that work on intra-abdominal pressure really kept taking me down the road of incontinence management, but that post was already long enough, so this one is going to get it’s own feature. I work with patients on managing urinary incontinence in every setting, so let me take you through some basics of how to do this. I am not a certified pelvic floor Physical Therapist and I only claim to know the absolute basics, but for many people, the basics are pretty helpful, and can at least buy time until they can get to a specialist if they need to. You may be thinking, “Why is this person who does mostly cardiopulmonary all day want to talk about urinary incontinence?” Well, most of my patients who have cardiopulmonary conditions like COPD or Heart Failure either have secondary effects of those conditions that cause incontinence or take medications that cause incontinence. So, out of necessity, I had to learn how to address these things.

This is a huge topic, also, so it’s going to be broken in to two parts. The first part is heavy on the what and the why so that you can have a really good understanding of the importance of managing this condition in patients across different setting. This will also help you have some great ideas for how to document what you are doing and why.

Why Is Urinary Incontinence Such a Problem?

Urinary incontinence straight up leads to disability. It may not be immediate, or it may be, but it’s a slippery slope and a short road. Urinary incontinence is extremely common, but it is NOT normal. It happens to both men and women, but definitely more often in women. When I was in PT school, we learned that about 80% of women will experience incontinence of some kind at some point in their life. Further research showed that this is also true of about 54% of men. That’s because incontinence doesn’t just come from childbirth, believe it or not. You can read more about things that cause stress incontinence in the post about intra-abdominal pressure, but we will go in to some detail here.

Urinary incontinence is the #1 reason women are placed in a facility as they age. That is because it becomes pretty hard to manage. There are many products that require purchasing, so it also becomes expensive. Incontinence is also among the leading causes for institutionalization of men as they age. This facility placement also typically leads to these men and women becoming dependent in their toileting, because they transition from what was otherwise a stress, urge, or mixed incontinence, to a functional incontinence. You can read more about that below, but basically, if there is no one available to help you, you eventually get to a point where you just go. This has been shown to increase depressive symptoms and severely impact overall well-being. Urinary management was the most-often reported impaired ADL in people over 65 years old, but it happens at ANY age.

And, finally, it is all potentially preventable. All of the journals cited in this article and several geriatric organizations agree that promoting continence or management of continence in the geriatric population is the most important factor in maintaining independence and well-being. But, it’s not just about the geriatric population, right? I did plenty of treatment for incontinence in outpatient orthopedics for patients of all ages, both men and women. Unfortunately, we often don’t see younger patients in therapy specifically for incontinence, but they do tend to come in for other issues… specifically back pain, hip pain, and core weakness! The incidence of stress urinary incontinence coexisting with low back pain is high, especially in women. This is where you come in. Let’s learn a bit more about Urinary Incontinence.

Types of Urinary Incontinence
  • Stress. We talked A TON about this stress in the article on intra-abdominal pressure regulation, so you can the details there, but overall, if you place enough stress on the bladder, it will empty. This type of incontinence happens when you cough, sneeze, stand up, hold your breath, turn over, strain… pretty much anything that can increase intra-abdominal pressure. This type is more common in women than in men, but, if you’ve seen men with abdominal hernias, you know it exists in men, too.

  • Urge. Sometimes called “key-in-door” incontinence, this type comes from a sudden and unexpected urge to urinate. This urge may be neurologic or reflexive in nature, like you always have to go when you get home from work so when you get to the door, you have the feeling that you have to go. It has been shown to be due to the combination of some type of reflexive or neurogenic trigger AND an overactive detrusor muscle (the muscle that surrounds the bladder). This urge can sometimes come from bladder irritation, too, and we will talk about what that means later. This type is actually more common in men than in women.

  • Mixed. This is the descriptor for some type of combination effect of both stress and urge incontinence.

  • Overflow. This one is pretty self-explanatory. When your bladder gets too full, it HAS to empty, whether you are ready or not. Sometimes, you just wait too long. Or, as with otherwise potty-trained children, they can get distracted by playing, and then they just go. Overflow incontinence can also happen when bladder emptying is impaired. This can happen by many mechanisms such as prostate enlargement, scarring of the urethra, detrusor weakness, or a bladder prolapse (cystocele). If the exit is blocked, nothing comes out.

  • Functional. This is the worst type of incontinence because it is 100% preventable. Functional incontinence is incontinence that happens when you can’t get to a bathroom safely or don’t have the help to manage the bathroom tasks that you need to perform. It can also result from shame, embarrassment, weakness, balance impairments, homelessness, and environmental barriers. Here is a clip of me talking about functional incontinence so you can get an idea of how this happens:

    Doctor B talking about functional incontinence in the aging population
  • Neurogenic. Neurogenic bladder results from some type of neurologic disruption to the bladder and its systems. This could be in a patient with spinal cord injury who cannot feel that their bladder is full. They no longer have the connections to the reflex mechanisms that send their brain that signal, so they have to perform intermittent catheterizations to empty on a regular schedule. Other neurological conditions, like Multiple Sclerosis, Cerebrovascular Accidents, Parkinson’s Disease, and many others can impact these reflex loops or their centers in the brain and result in a neurogenic bladder. Trauma can also lead to this condition if there is damage to the sympathetic (T10-L2) or parasympathetic (S2-4) trunks that innervate the detrusor muscle.


And, as with many things, the likelihood of urinary incontinence increases with age. This is due to many factors, but the compounding of these factors, like the increased number of comobordities accumulated with age, increases the risk of urinary incontinence. There are several health conditions that result in different types of urinary incontinence by direct of indirect mechanisms. The American Society of Nephrology produced this great table that gives you a good overview of the things that can cause urinary incontinence.

American Society of Nephrology

I want to point out, specifically, the line in this table on “Bladder contractile strength”. There are so many things that change the ability of the bladder to contract appropriately, and most of my patients have at least one of the items on that list in their medications list of past medical history. The bladder is surrounded by a muscle, right? And it has neurological inputs and outputs and can be strengthened, just like any other muscle! And you are a Physical Therapist, isn’t that what you do? So let’s take the first step:

Identifying Urinary Incontinence

No one really wants to talk about it. No one really wants to admit it. So, you can’t just ask, “Do you pee your pants sometimes?” because it won’t get you any useful information. In the home setting, it’s probably most beneficial to just look around. You’ll see what you need to see if someone has incontinence. There will be products readily available in the bathroom, and there may even be soiled clothing laying about. In the outpatient setting, it’s a bit tougher because you can’t take as many nonverbal clues. You have to get crafy in your questions! Here’s how I go about this:

“Do you ever have any urine leakage?”
“Do you ever have any other type of leakage?”
“What about when you cough or sneeze sometimes?”
“Do you ever need to use any products for leakage like pads or undergarments?”
“How often do you need to change those in a day?”
“Do you notice you have leakage with any certain activities?”


And just because they answer “No.” to the first one, doesn’t mean I don’t ask the others. Often times I will get “No,” as the first answer, but then yes to several of the other questions. It is also incredibly important to follow up this series of questions with a conversation about how, although this is common, it is NOT normal, and can be improved or resolved very easily, even if it has been happening for a long time. You may also need to add a conversation about how pads and undergarments are only a band aid, not a solution, but we will get more into that later.


How is Urinary Incontinence Treated?

Well… here’s the thing. Most people who have it don’t treat it. They simply think it’s normal. Most of them are women who have had children and they just think that’s how things are. BUT IT’S NOT TRUE. Other treatments tend to focus on type and cause. Normalize the situation, but also normalize treatment. Many people will be ashamed or embarrassed and they will need you to coach them through that in order to make progress toward a solution.

Using liners, pads, or briefs allows urine and other body waste to stay in contact with the urethra, resulting in some of it working it’s way back in. The result, especially in older adults and those who are immunocompromised, is a urinary tract infection. Urinary tract infections (UTIs) are incredibly common (but also NOT normal) and the incidence is rising. This is a much bigger problem than most people realize and here’s why: Antimicrobial resistance, also known as super bugs. The number of hospitalizations for UTIs is rising year after year, especially over the summer months, and doctors think that this is due to patients being previously treated for UTIs but returning due to a developed resistance to antibiotics.

Urinary tract infections are hugely problematic. They are incredibly dangerous and can result in sepsis, falls, temporary or permanent mental status changes, and continually decreasing urinary health and function. All of which results in decreased functional ability, hospitalization, institutionalization, or even death. They also contribute to the aforementioned building concern for drug-resistant microbes. I may not be a pelvic floor therapist, but I’m pretty darn vocal about this! Here are the types of urinary incontinence and how they are typically treated at the present. Hopefully we can make some serious changes!

Stress incontinence. As a secondary effect of other comorbidities, stress incontinence can be treated with medications and other interventions for the comorbidities, along with retraining of how they regulate their intra-abdominal pressure. As a primary diagnosis, regulation of intra-abdominal pressure and pelvic floor strengthening exercises are usually the keys to success.

Overflow incontinence.
Treated by removing whatever blockage is present to the urethra. This typically involves surgical repair for prolapses, bladder suspension, or prostate removal. Unfortunately, these procedures come with a laundry lists of side effects and effectiveness is questioned. If the blockage cannot be removed, intermittent catheterization or indwelling catheters can be used, but have serious potential for problems.

Urge incontinence. May be due only in part to an overactive detrusor muscle, but is typically only treated using medications that target relaxation of the detrusor muscle. Unfortunately, this can result in over-relaxation of all the muscles or just the detrusor muscle which then results in several other issues. And, this treatment only treats half the problem! We now that there is a neurological component to urge incontinence.

No Treatment. Most commonly, there are those who don’t treat it, but attempt to manage it using liners, pads, or briefs, effectively allowing it to happen, but not letting anyone else know it is happening. In men, catheterizing is a common technique to address incontinence. Here’s the problem with all of that:

Infection.


This is Serious! I Need to Treat This! What Do I Need to Do?

Physical Therapists play a very large role in managing urinary incontinence. If you read through that table from the American Academy of Nephrology, I’m sure you noticed that most things on the list are things we can address in some way, whether it is a medication reconciliation, a lifestyle change, and environmental change, or physical intervention. There are going to be LOTS of options for you to chose from for your patients. There is something for everyone! So make sure to check back!

Reduce modifiable factors

Some things you can change, some things you can’t. So work with what you can change. You can’t change someone’s age, gender, or disease. You can change their location (maybe), their available help (maybe), their medications (maybe), their mental state and function (maybe), their BMI (maybe), their safety, their functional ability, their strength, their diet, and their environment. A lot of maybes… But this gives you many different avenues from which you can launch your treatment. Let’s attack the maybes first:

If you band together with some of your healthcare team, you can address some of these maybes pretty well. You can work with a social worker to get in-home help or find suitable supportive placement. I know that institutionalization is not the best answer, but sometimes it’s the only answer, and sometimes its better than being alone and unsafe, but you can also consider short term rehab facility placement. You can work with the primary care doctor (or urologist and cardiologist, if you are lucky) to change medications or reduce dosages to reduce cognitive effects, stabilize fluid dynamics, and reduce fall risk. You can work with family to arrange for in-home assistance. And, as a skilled rehab provider, you can get someone going on an exercise program to begin chipping away at their BMI.

Other than the maybes, we have some pretty tangible stuff in this list that Physical Therapists are pretty poised to address. These are some of the things I was talking about when I mentioned the lifestyle changes. Let’s take a look at those:

01


Environment

Take a look around. Reduce barriers, ensure safety. Turn lights on, make paths short and straight. Make sure they have the appropriate assistive device.

02


Functional Ability

The path is great, but we have to get to it. Make sure they can get out of a chair by elevating it if needed.

03


Diet & Fluids

More water is better. I know this is counterintuitive, but it’s important. Reduce or eliminate bladder irritants.

04


Strength

Lower extremity strength, Upper extremity strength, core strength, pelvic floor muscle strength… Pick one or several, depending on your patient’s needs.

Bladder Irritants? Yes, that’s a thing.

Over-concentrated urine is a bladder irritant, so cutting water intake should not be an option. Keeping a patient with heart failure or ESRD within their approved water intake is important, but reducing it is not a solution. Many patients like to cut out liquids before bed so they won’t have to get up to use the bathroom at night. Although this strategy sounds plausible, it results in increased urine concentration and your patient will actually have to get up more often. Patients who are returning to a healthy water intake after restrictions will initially experience an increase in urinary frequency, but their body will regulate with time. If your patient doesn’t like water, have them gently flavor it with flavor drops (not powder or sugar-based drink flavors) or fruit.

Some food and drinks are also bladder irritants. As much as it pains me to say it: Coffee. Technically, caffeine is the culprit, though. Let me tell you this little pearl: DO NOT tell your patient to stop drinking coffee. You’ll lose them immediately. Ask them, instead, to alternate a cup of coffee with a cup of water. Other highly caffeinated drinks like soda are also on this list, as well as highly acidic foods and liquids. Citrus fruits, tomato products, and spicy foods will all result in increased urge or frequency or both. However, diluting these irritants can help, so keep the water flowing.

Another one that will get you gaffs if you suggest it’s removal is alcohol. Alcohol, much like coffee, dehydrates you, increases urine concentration and causes bladder irritation. Like I said with coffee, don’t suggest eliminating it, suggest diluting it by alternating with water. If your patient is treating their urinary incontinence with medications, you’ll want to advise removing alcohol completely as it has severe interactions with some of these medications.

Bladder Retraining Programs

This is where a referral to our magical friends in the pelvic floor rehab arena are called upon. We create voiding schedules for our patients with spinal cord injury, and this process is similar. If you have established a reflexive (literally, neurological reflex loop) habit of going to the bathroom at a given time of day or before/after a certain activity, your brain will learn this pattern and make it happen. These schedules can be helpful to maintain continence, but they can also be detrimental if they are not created intentionally. Remember that “key-in-door” incontinence we talked about? What if you can’t find your keys? Problem! Try going before you leave work. Then you’ll know you don’t actually have to go and you can calm your jets.

It is extremely important to remember that our body has an alarm system for a reason. Our bladder sends signals to our brain to say, “Hi there, I’m full! Time to empty me. Better find a bathroom soon.” If we don’t respond to these signals, they will intensify, “Hey, I’m telling you I gotta go, so let’s go! Now!” And as long as you get there, that’s great. The system worked. But this can go awry in two ways.

  1. What if you can’t get there?
    This is where functional incontinence happens. If you can’t get there even though you know you have to go, you need to identify the reason. Strength, environment, endurance, etc… See the list above. If you don’t get there, overflow happens and you go anyway.
  2. You keep ignoring the signals.
    This actually creates a negative learning loop. If you ignore the signals enough, the body and brain figure out that the signals aren’t working and the bladder stops sending them. BAD PLAN. Now how the heck are you going to know when you have to go? And we end up in overflow again with no warning.

Your local pelvic floor therapist is going to be the best one to help you figure out these schedules, reflexes, and learning loops to best set up a schedule that fits your patient’s personal needs. Don’t forget that incontinence happens at all ages, so we may need to consider school and work schedules when timing bathroom breaks.

Finally… Pelvic Floor Muscle Strengthening and other Bladder Management Techniques

This is where I’m going to leave you in a bit of suspense! This post is already getting pretty long and complex, so I’m going to make treatment options an entirely different post. Stay tuned! I’ll link Part 2 once it is published.


So much to think about and so many people we can help! I once was able to resolve functional incontinence in a patient simply by having her turn on the bathroom light prior to entering. It can be that simple! Do you have a story about a lifestyle change that significantly improved incontinence? Tell me your story in the comments!

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More on How Physical Therapists Manage Chronic Disease!

Chronic Disease Part 2: Chronic Obstructive Pulmonary Disease (COPD)

This is part 2 in a multi-part series on the role of Rehab Providers in the management of chronic disease. Don’t forget to check out Part 1: Heart Failure! Chronic Obstructive Pulmonary Disease is a widely diagnosed disease of the lungs that includes the diagnoses of emphysema and chronic bronchitis. COPD can be caused byContinue reading “Chronic Disease Part 2: Chronic Obstructive Pulmonary Disease (COPD)”

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References

Ayeleke, R. O., Hay-Smith, E. J., & Omar, M. I. (2015). Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women. The Cochrane database of systematic reviews2015(11), CD010551. https://doi.org/10.1002/14651858.CD010551.pub3

Bush, H. M., Pagorek, S., Kuperstein, J., Guo, J., Ballert, K. N., & Crofford, L. J. (2013). The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-Sectional Study. Journal of women’s health physical therapy37(1), 11–18. https://doi.org/10.1097/JWH.0b013e31828c1ab3

Carvalho, N., Fustinoni, S., Abolhassani, N. et al. Impact of urine and mixed incontinence on long-term care preference: a vignette-survey study of community-dwelling older adults. BMC Geriatr 20, 69 (2020). https://doi.org/10.1186/s12877-020-1439-x

Kuchel, G. A. and DuBeau, C. E. (2009). Urinary Incontinence in the Elderly in Geriatric Nephrology. American Society of Nephrology. Retrieved from https://www.asn-online.org/education/distancelearning/curricula/geriatrics/Chapter30.pdf

Mayo Clinic. (2020). Bladder Control: Lifestyle strategies ease problems. Retrieved from https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/bladder-control-problem/art-20046597

Nuotio M, Tammela TL, Luukkaala T, Jylhä M. Predictors of institutionalization in an older population during a 13-year period: the effect of urge incontinence. J Gerontol A Biol Sci Med Sci. 2003 Aug;58(8):756-62. doi: 10.1093/gerona/58.8.m756. PMID: 12902536.

Simmering, J. E., Tang, F., Cavanaugh, J. E., Polgreen, L. A., & Polgreen, P. M. (2017). The Increase in Hospitalizations for Urinary Tract Infections and the Associated Costs in the United States, 1998-2011. Open forum infectious diseases4(1), ofw281. https://doi.org/10.1093/ofid/ofw281

Welk B, Baverstock R. Is there a link between back pain and urinary symptoms? Neurourol Urodyn. 2020 Feb;39(2):523-532. doi: 10.1002/nau.24269. Epub 2020 Jan 3. PMID: 31899561.

Zilberberg MD, Shorr AF. Secular trends in gram-negative resistance among urinary tract infection hospitalizations in the United States, 2000–2009. Infect Control Hosp Epidemiol 2013; 34: 940–6.

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Pressure… Pushing Down On Me…

Breathing. I can’t stress it enough. If you’re not breathing, you’re dead… or in a lot of pain… either way, it’s not good. So breathe! In my practice, I work with a lot of different types of patients with a wide variety of conditions and comorbidities, but they all have one thing in common: they breathe. My guess is that your patients have this in common with my patients, even if you are in an outpatient orthopedic clinic, or a skilled nursing facility, or a pediatric rehab hospital. So it goes without saying that one of the main interventions I provide for all of my patients in proper breathing to promote physiological function and mobility. I base many of these interventions on the regulation of intra-abdominal pressure. I had no idea how broad this topic would become once I got started!

Intra-abdominal pressure is a huge factor in many disease states, post surgery, and with impaired mobility. If I can regulate someone’s intra-abdominal pressure, odds are I can help them breathe better, move better, reduce their pain, and even make it to the bathroom on time. Why is that? Because that pressure inside your abdomen pushes on everything else in there and elsewhere! These changing pressure dynamics are really important for digestion, breathing, posture, urination, circulation, neurological function and hemodynamic stability. Don’t believe me? Ask Mary Massery! She will tell you all about it! Normal Intra-abomdinal pressure at rest ranges from 13-20 mmHg depending on the position (supine vs sitting vs standing). When you jump or cough, that pressure can go as high as 171 mmHg in young healthy people.

Photo by Victor Freitas on Pexels.com

If you work on the opposite end of the spectrum of patients from me (i.e. the super fit, young, healthy folks) then you might try to regulate intra-abdominal pressures in your athletes for very specific reasons. Weightlifters and powerlifters tend to utilize intra-abdominal pressure to brace when they lift very heavy loads. Techniques vary, but using that pressure and the braces they wear around their abdomen, they can push out a large amount of power. However, lifters also tend to suffer some of the side-effects of using intra-abdominal pressure such as urinary or fecal incontinence, aneurysms, and blood pressure issues. Strangely enough, these are some of the exact same things post-partum women experience and for exactly the same reasons. Intra-abdominal pressure is used to push babies out, too! Let’s dig in to those a bit more.


Who Has Increased Intra-Abdominal Pressure?

The number one reason I work on intra-abdominal pressure is far and away to reduce urinary incontinence. Think about it. All that pressure inside your abdomen pushing down on… your bladder! The standard method for measuring intra-abdominal pressure is actually to measure it through the bladder! Your bladder can only take so much and eventually won’t stand to the pressure and it will let go. This is called stress urinary incontinence and 80% of women and 45% of men will experience this at some point in their life. In addition to incontinence, this pressure can also cause over-lengthening of the ligaments that hold your organs in place. This can result in herniation of the organs through the abdominal wall (I’m sure you’ve seen plenty of these) or prolapse of the pelvic organs. All things that we ABSOLUTELY DO NOT WANT.

The pelvic floor muscles can normally accommodate to this pressure for short periods of time, but sustained pressure or large amounts of pressure will eventually cause the pelvic floor muscles to either fatigue or lengthen beyond their ability to efficiently contract. After these events, the amount of intra-abdominal pressure that causes incontinence episodes becomes less and less and herniations and prolapses increase more and more. You may be thinking that this is important for post-partum women, but intra-abdominal pressure regulation is also incredibly important for people who have COPD, Heart Failure, Obesity, Cirrhosis, neurologic conditions, and a host of other chronic diseases. That’s because all of these diseases cause changes to intra-abdominal pressure in some way.

Photo by Anna Tarazevich on Pexels.com

For COPD, these patients are coughing frequently. This repeated coughing causes sustained stresses on the pelvic floor muscles and the increased lung volume in obstructive lung diseases increases the pressure within the abdomen. For heart failure, the increased amount of fluid accumulated leads to increased pressure in the abdomen, especially if they experience ascites (accumulation of fluid in the abdomen). Obesity also leads to increased intra-abdominal pressure as the build up of fatty tissue within in the organs takes up space, therefore increasing pressure. With cirrhosis, the liver increases in size due to one of many possible reasons such as edema or fat build up. This takes up extra space in the abdomen, increasing the overall pressure. Tumors or other space-occupying lesions in the abdomen create the same effect. Neurologic conditions can result from increased intra-abdominal pressure, but can also create changes in intra-abdominal pressure. And then, people can have more than one of these conditions and every additional breath can become a turn of the vice. All of these things are becoming so much more common that abdominal hypertension has become a typical diagnosis that can lead to severe health conditions.


Why Do We Need to Regulate Intra-Abdominal Pressure?

Pulmonary conditions are front and center right now thanks to the global COVID-19 pandemic, we will start there. There have actually been cases documented of compression atelectasis (too much fluid in the abdomen increasing pressure so high that the lungs have no where to expand) causing multi-system organ failure. Compression to this level, although somewhat rare, causes internal organ compression to the point of ischemia. This means that all the organ systems can’t get blood because the blood pressure cannot overcome the intra-abdominal internal pressure. As Physical Therapists, we are pretty familiar with compartment syndromes, so to compare, this condition is also known as abdominal compartment syndrome. You can imagine that the intestines, kidneys, and pretty much everything else in the abdominal compartment doesn’t fare well under these conditions. Abdominal compartment syndrome can also be a complication of child delivery.

Returning to our post-partum patients, women who have Cesarean sections (C-sections) need to reduce intra-abdominal pressure when they move to reduce strain on their incision or surgical work. This is also true for most people who have had any kind of abdominal surgery such as hysterectomies, laparatomies, laparascopies, and trachelectomies, and several spinal surgeries such as decompressions, fusions, etc. I’ve also found reducing intra-abdominal pressure to be extremely helpful for people who have had new colostomy placements, as they have decreased pain with movement and decreased complications with their colostomies. We will go in to more detail on all of this later.

Reducing intra-abdominal pressures is crucial in patients with chronic health conditions such as COPD, heart failure, cirrhosis, obesity, and many others. Why, you might ask? They don’t have surgical incisions or internal work that they pressure is pushing on, so what can we do. I’ll take you back to the very first word of this post. You can help them BREATHE. You are essentially providing interventions to improve V/Q matching, because you are allowing increased ability to ventilate and, therefore, increasing potential to diffuse and perfuse. In addition to breathing, most of these patients also experience some kind of incontinence. This is, in large part, due to the increased intra-abdominal pressures, but also due to the effects of medications and altered fluid dynamics. You can’t change the medications or disease, so change the pressure.

Photo by Perchek Industrie on Pexels.com

The neurological population (which we will discuss more in a bit) also struggles with increased intra-abdominal pressures. We will dive deep into the neurologic mechanisms by which this effects the body, but increased intra-abdominal pressure actually impairs the flow of cerebrospinal fluid in the central nervous system. These pressures can also increase venous distension which puts direct back-pressure on the eyes and optic nerve. All of the major neurological components of function are negatively impacted by high intra-abdominal pressure.


Do I Always Want to Reduce the Pressure?

Well, no. Just like everything else in the medical world, nothing is ever “always.” Even lab values that are “not compatible with life” can still be seen in calm living individuals. So, no, you don’t always want to reduce intra-abdominal pressure. In fact, sometimes you want to increase it!

For patients who have medical conditions like Parkinson’s Orthostasis, Postural Orthostatic Hypotensive Syndrome (POTS), or even just your standard orthostatic hypotension, you actually want to INCREASE intra-abdominal pressures, at least temporarily. We achieve this in the short term by actually instructing patients to hold their breath during an activity. This places pressure on their internal vasculature, holding blood up into their brain when gravity says otherwise (like with orthostatic hypotenison: when the patient goes up, their blood – and blood pressure – go down), which can help reduce symptoms of dizziness or blacking out. Obviously we have to let them breathe and return intra-abdominal pressure to normal eventually but we hope to get them active enough to keep the pressure up (usually with some exercise). In the long term, we can use devices like abdominal binders and compression garments to increase the pressure.

For post-partum patients, abdominal binders are also frequently used. This can be for several reasons, but you may actually want to increase their intra-abdominal pressure to apply compression to reduce internal bleeding (there can be a lot of bleeding with and after birth). It is also documented that intra-abdominal pressure can elevate significantly even in healthy pregnancies. This should seem obvious because there is a human growing in a limited space so the pressure has to go somewhere. But, because this is a slow process, pregnant patients tend to accommodate to this pressure over time. However, that tiny human and all it’s stuff leaves the abdomen quickly, which is a harder process to accommodate to. Birth also creates a large fluid deficit which can leave a post-partum patient a bit hemodynamically unsteady. These factors cause the intra-abdominal pressure to drop and some patients may need some pressure support for a while to return to activities normally.

Photo by cottonbro on Pexels.com

Other conditions that cause significant fluctuations in hemodynamic stability, such as severe burns, dehydration, mid-brain injuries, and multi-traumas may also require pressure support for some time.


The Valsalva Maneuver

Some people try to increase their intra-abdominal pressure intentionally on their own. This is typically done using a Valsalva maneuver, or “bearing down”. People use this to place intentional pressure on their organs to achieve a certain goal. This may be to push a baby out, to defecate, or to stabilize their spine. However, using a Valsalva maneuver too often or several times in a row can lead to vasovagal syncope. We mentioned the vagus nerve above and you can see in the drawings below that it provides innervation to the vasculature of the abdomen. Put too much pressure on the vasculature of the abdomen (aka the abdominal aorta) and you will lose pressure support for the blood flow to your brain and you’ll faint. The mechanism also may occur from that pressure causing overstimulation of the sympathetic nervous system resulting in a severe “faint” response, which is your body’s only way of forcing you to stop producing the pressure. It’s basically a safety mechanism to prevent abdominal compartment syndrome.

Alone, vasovagal syncope isn’t dangerous and is usually self-limiting. Just like when you hold you breath long enough, your body will force you to breathe somehow, even if it’s by making you pass out so that you breathe again. However, it’s what happens after you pass out that concerns us. I’ve treated several patients for head injuries, wounds, and broken bones secondary to the fall they experienced during their syncopal episode.

Valsalva Maneuvers are not a great solution to pelvic organ function. This increased pressure to go to alleviate constipation is not effective and has significant side effects. If you are in need of better options, please check out the post on Incontinence Management – Coming Soon!


So What Do I Do To Help These Patients Breathe?

Thankfully, that’s the easy part! Odds are, you already know this, you just may not know the deeper “why” behind why you do it or how to widely apply it. I’m sure you are constantly telling your patients to breathe during their exercises. And I’m sure they repeatedly hold their breath. Mine do! Which tells us they are attempting to stabilize and produce force improperly, i.e. not using their muscles.

If you read my post on pursed lip breathing, I told you a little bit about this. In that post we talked about how pursed lip breathing, when done correctly, can stimulate the parasympathetic nervous system to reduce anxiety and calm the sympathetic responses. I just used this with a patient recovering from COVID-19 very successfully. When she started to get short of breath and panic, we regulated her breathing and her oxygen saturation sprang right back up. But regulating breathing by changing intra-abdominal pressures can help with so much more! I’m going to take you back to the basics of what you know.

The reason behind this effect is the change in intra-abdominal pressure which changes forces and stimulations to the sympathetic trunks within the abdomen. Applying our anatomy knowledge, we can picture that. Remember the sympathetic trunks from all those years ago? They are coming back. Look at those abdominal sympathetic trunks! They are all over the length of the spinal column from the diaphragm to the pelvic floor and there are more throughout the length of the spine. They feel EVERY change in intra-abdominal pressure and they respond to it. They feel the pressure, they get stimulated and they set off the fight, flight, or faint responses, because that’s their job! Most of the time, we see this manifested as the patient getting anxious, worked up, angry, or refusing to participate. We can also see increased pain or fainting (like we talked about above).

So, by reducing the pressure, thereby reducing the stimulation on the sympathetic nervous system, we calm the fight, flight, or faint response mechanisms. Like we talked about in the post on pursed lip breathing, we also then engage the parasympathetic systems. The parasympathetics mostly branch from Cranial Nerve X: The Vagus Nerve. The remainder of the parasympathetics come from the sacral trunks. Reduce strain on the pelvic floor, and the parasympathetics can do their job.

And, don’t forget, you aren’t just utilizing the autonomic functions to regulate breathing, you are also increasing space for the lungs to expand. This increases the potential for vital capacity, increases the space for residual volume, and reduces the required PEEP, meaning you will have more patent airways. Increased intra-abdominal pressures actually start to require a higher than normal PEEP (positive end-expiratory pressure) to maintain patent airways. Eventually, the body can’t create a high enough natural PEEP to keep breathing properly. Reducing intra-abdominal pressure increases the available space for lung expansion with inhalation, reducing the effort and increasing the efficiency of breathing, and reducing the required PEEP. Significant improvements are noted on Pulmonary Function Tests (PFTs) including improved FEV1 and improved FRC, both markers of overall pulmonary function, when intra-abdominal pressure is reduced.


How Can I Reduce the Pressure So These Patients Can Breathe and Move Better?

After spine or abdominal surgery or birth, patients are NOT taught how to move! They strain. They hold their breath. They endure. Or they don’t move at all. Patients who have chronic diseases have been slowly accommodating to increased intra-abdominal pressure and changes in lung volumes and compliance over time, so may not feel an acute change in their symptoms. But, all of this is 100% avoidable. And, oh so simple. This is where you come in.

If your patient is having pain with movement post-operatively, go to your basic techniques and then we will build on them a bit. We know for post-operative spine patients, log rolling is very important to prevent them from breaking their movement and positioning precautions, but this concept can be applied broadly. Especially for patients who have abdominal incisions, we need to decrease the tissue strain or they are going to hold their breath because of pain. Then, we have to pair breathing with the movement to reduce sympathetic activation and reduce intra-abdominal pressure so that muscles can function properly with an appropriate vitals response. Here are the steps for something simple:

Getting out of bed
  1. Start in Supine (lowest intra-abdominal pressure)
  2. As they breathe out: Slide one foot up the bed while breathing out through the whole motion, breathe in
  3. As they breathe out: Slide the other foot up the bed while breathing out through the whole motion (this brings you to hooklying), breathe in
  4. As they breathe out: As a whole unit, roll on to one side while breathing out through the whole motion, breathe in
    1. Patient may need to use grab bars, trapeze, bed rails, drop knees to the side, UE support from you, or momentum from swinging UEs
  5. From sidelying, position hands near head and shoulder on bed to push up to sitting and bring feet forward over edge of bed while breathing out
  6. With or without assistance, push up from the arms and drop feet downward to the floor while breathing out through the whole motion (this achieves sitting which created only small increases in intra-abdominal pressure in comparison to supine).

I know that seems like a lot of steps, but it moves rather fluidly once you teach it. It is so important to break the task down and ensure the patient moves slowly and breathes out (exhales) with each position change. This reduces the intra-abdominal pressure during movement, keeps tissue strain to a minimum, and also keeps that sympathetic nervous system quiet so the patient can focus on moving. If your patient uses supplemental oxygen, make sure they are breathing in through their nose so they can utilize it most effectively to maintain V/Q matching. And, even though this is a lot of steps which increases the time required to perform this activity, your patient will thank you for the increase in their comfort. They won’t have to do it this way forever, just until they recover from their surgery.

Now you can take these concepts and apply them widely, like with sitting down on the toilet, or getting up from the floor, or with performing their exercises in the gym like their next plyo task or weighted deadlift. If your patient experiences pain or difficulty breathing with movement, you’ll likely see a decrease in either or both symptoms because of those mechanisms we discussed above. In the post-partum population, you may find that your patient needs both pressure support and pressure reduction depending on the movement task.

If you are using intra-abdominal pressure regulation to help treat your patients with stress incontinence, there are some specific ways you need to build breathing in to you exercises and other treatments. Remember how we talked about the pressure this places on the pelvic floor? Yea, you have to reduce that pressure if you want your patient to have the proper length-tension relationships in their pelvic floor muscles to even attempt a proper muscle contraction. It is so often that people hold their breath while performing pelvic floor exercises. I like to tell my patients that those particular muscles are NOT breathing muscles. They laugh, which then means they are breathing, which makes me happy, and then we try again. I think that leads me to my next post on incontinence management… See you there!


Even if you already knew about these interventions, I’m hoping that you now can better utilize them for a wider variety of patients. I also hope you have a really good understanding of WHY you use these techniques. How do you use intra-abdominal pressure regulation in your patients? Tell me in the comments!

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More Reads…

Blow Out the Candles…

If there is any treatment that I feel like gets used in a cookie-cutter fashion, it’s pursed-lip breathing. As much as I hate seeing this technique used for every single patient that has shortness of breath, it does have clinical usefulness. So let’s talk about how to implement pursed-lip breathing properly based on patient presentationContinue reading “Blow Out the Candles…”

Cobb, W.S., Burns, J.M., Kercher, K.W., Matthews, B.D., Norton, H.J., Heniford, B.T. (2005)
Normal Intraabdominal Pressure in Healthy Adults. Journal of Surgical Research. 129(2):231-235. https://doi.org/10.1016/j.jss.2005.06.015.

Depauw, Paul & Groen, Rob & Van Loon, Johannes & Peul, Wilco & Malbrain, Manu & De Waele, Jan. (2019). The significance of intra-abdominal pressure in neurosurgery and neurological diseases: a narrative review and a conceptual proposal. Acta Neurochirurgica. 161. 1-10. 10.1007/s00701-019-03868-7.

Frezza, E.E., Shebani, K.O., Robertson, J. et al. Morbid Obesity Causes Chronic Increase of Intraabdominal Pressure. Dig Dis Sci 52, 1038–1041 (2007). https://doi.org/10.1007/s10620-006-9203-4

Mayo Clinic. (2021). Vasovagal Syncope. Retrieved from https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/symptoms-causes/syc-20350527#:~:text=Vasovagal%20syncope%20(vay%2Dzoh%2D,blood%20pressure%20to%20drop%20suddenly.

Sugerman, H.J., Bloomfield, G.L. & Saggi, B.W. Multisystem organ failure secondary to increased intraabdominal pressure. Infection 27, 61–66 (1999). https://doi.org/10.1007/BF02565176

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Blow Out the Candles…

If there is any treatment that I feel like gets used in a cookie-cutter fashion, it’s pursed-lip breathing. As much as I hate seeing this technique used for every single patient that has shortness of breath, it does have clinical usefulness. So let’s talk about how to implement pursed-lip breathing properly based on patient presentation and medical history so that you can use this most effectively and appropriately. This is going to take up down some roads, both general and specific, to help you understand what pursed-lip breathing does and how it should be used. But, first, let’s watch a pretty decent video on pursed-lip breathing. This video incorporates several different techniques along with pursed-lip breathing, but doesn’t give a whole lot of clinical specifics which makes it GREAT for patient education. You’ll need to clarify the specifics for your patient based on their needs.

American Lung Association

Let’s start at the beginning: What is Pursed Lip Breathing?
Pursed-lip breathing is a respiratory technique with many uses depending on how it is implemented. The general purpose of pursed lip breathing is to prolong exhalation, slow respiration, and provide positive pressure to breathing. Overall, this technique can improve vital capacity and tidal volume.

Sounds simple enough right? We hear the same cues used all the time: “Smell the roses, blow out the candles,” but I have to tell you… If you think you know, you have no idea. This is so much more complex than we give it credit for. Let’s break this down by diagnosis…


Restrictive lung diseases:
Lung resection, sarcoidosis, chronic atelectasis, pulmonary fibrosis including interstitial lung diseases, COVID-19 and other viral/bacterial pneumonias, pleural effusion

There is no amount of deep, diaphragmatic, or pursed lip breathing you can do that will change the fact that these patients have restricted lung volume. You can’t get air in if there is nowhere to put it, you cannot use what just isn’t there. Pursed lip breathing can still be used for these patients, but the use is NOT to improve vital capacity, because that won’t happen. When people with restrictive lung conditions become short of breath, it is typically associated with a high level of stress and anxiety because they literally can’t breathe. Their lungs are closing down or scarring up or any other mechanism that reduces viable lung tissue amount or function.

Pursed-lip breathing can help these folks, for sure, but it is through mechanisms that are emotionally and autonomically linked to breathing. Mindfulness of breathing has been shown by numerous studies (thank you, yoga and tai chi!) to change a person’s emotional state and physiological function. This mechanism is well studied but very complex and involves chemical transmitters as well as stretch-response mechanisms in the musculoskeletal, vascular, cardiac, olfactory, and limbic systems (and probably several others). It is important to note that the slowed rate of breathing is the emphasis of the research, not necessarily the “pursed-lip” portion of the technique.

Photo by Anna Shvets on Pexels.com

That all being said, please use pursed lip breathing in this individuals for the purpose of decreasing anxiety and respiratory rate. Keep in mind that this may only be a band-aid and that medications, increased oxygen titration, and other medical interventions may be necessary to recover shortness of breath. Pursed lip and diaphragmatic breathing can be used together to stimulate the autonomic nervous system (chemo-, baro-, and stretch-receptors) to reduce respiratory rate and chemically alter emotional state to reduce stress and anxiety and lessen symptoms of shortness of breath. This is based in parasympathetic activation which slows heart rate and relaxes smooth muscles throughout the body. This means arteries relax and are able to carry more oxygen rich blood to needed organ systems, blood pressure lowers, and cardiac effort is reduced due to reduced peripheral resistance. All good things for someone who is experiencing shortness of breath 🙂

Unfortunately, research shows us that pursed lip breathing may also increase the overall metabolic workload of breathing in patients with restrictive lung diseases, which may outweigh the benefits if you are attempting to increase oxygen saturation with activity. It has also been found that pursed lip breathing is not effective to reduce shortness of breath during activity in patients with restrictive lung diseases. So, although it may seem pretty simple, this intervention does need to be used with caution and for the right reasons.


Obstructive Lund Diseases:
Chronic Obstructive Pulmonary Disease, Bronchitis, Bronchiolitis, Emphysema, Cystic Fibrosis, Asthma

This one is the big red flag for me. The video does a pretty decent job of showing how to accommodate pursed-lip breathing to obstructive conditions, but doesn’t exactly explain the reasoning. The big problem with obstructive lung disease is that you can’t get enough air OUT of the lungs. Therefore, telling someone to breathe in deeply through their nose is NOT going to improve their symptoms! In fact, it will actually make things worse because you are just attempting to pack more air in to a space that is already full of dead air. This does not improve ventilation, and significantly reduces ventilation/perfusion matching requirements of activity. In essence, the more you have them breathe deeply, the less oxygen they have left in their blood supply to actually perform the mechanical work of breathing!

To perform pursed lip breathing properly in a patient who has obstructive lung disease, you have to have them focus on the breathing OUT portion of pursed lip breathing. And this activity is two-fold in benefits! Here’s why:

The video instructs pretty well on the importance of breathing out and incorporates a great tool I teach to my patients all the time: Counting! Patients with obstructive lung conditions need to get more air out than they take in. This helps remove the dead air from their lungs and replaces it with new air. The more air they breathe out, the more room they have to put new air in. Make sense? So having your patient count, “1, 2” for their breath IN and “1, 2, 3, 4” for their breath OUT helps them focus on getting the air out. Sometimes I add in a PEP device to help shift to focus to getting air OUT for patients with obstructive conditions.

Photo by Anna Shvets on Pexels.com

The second bonus to focusing on exhalation is the actual performance of the “pursed-lip” portion of pursed-lip breathing. This maneuver, when done properly, causes some of the air coming out of the lungs to bounce off the inside of the lips and cheeks and rebound into the airway and lungs. This is similar to PEEP (positive end-expiratory pressure). We provide PEEP when patients are mechanically ventilated with the exact same purpose it fulfills with pursed lip breathing: to provide back pressure that splints open smaller or collapsed airways, allowing for exhalation of greater volumes of carbon dioxide, therefore improving vital capacity. That means that the little bit of back pressure holds the airways open longer to allow for more dead air to escape, making room for more good air to get back in.

And when I say “done properly,” I don’t mean that you try to force air out through whistle-tight lips. That just doesn’t allow for that back pressure to build up correctly. Just like in mechanical ventilation, too much PEEP can be a problem. Lips should still be open somewhat and the cheeks should be loose and allowed to flare so that air can gather and build pressure. Here’s a terrible up-close video of me pursed-lip breathing so you can get the idea.

Like I said, pretty terrible up-close video, but I’m not pinching my lips together super tight and my cheeks are relaxed and that’s really the point here.

There have been some recent studies that have shown that a simulated pursed-lip breathing during non-invasive ventilation (NIV) can actually be more effective than NIV alone for patients with COPD who are in hypercapnic respiratory failure! This intervention even held up under activity demands of a functional maximal exercise capacity test (the 6 minute walk test).


Did you know there was that much to it? I know I was shocked to find out something that seemed so simple was actually so complex and that it could be used in such varying ways if it was used correctly. I hope that you are able to repurpose this old stand-by technique with better clinical application for your patients.

I’ve gotta tell you all something… I love this stuff. I love getting down to the absolute basics, figuring out the “why” of it all, applying it in the best possible way for my patients, and then telling all of you about it! Now, pucker those lips and get to breathing!


Do you find that pursed-lip breathing recovers shortness of breath better for your restrictive or obstructive patients? Let me know in the comments!

Read more from the Pulmonary Rehab Toolbox!

Postural Drainage

We’ve all seen that dreaded picture in our textbooks… All the human figures laying in so many different positions with pillows and tables tilted all over… and I very clearly remember thinking, “How on earth am I supposed to remember all of those?” Well, good news. You really don’t have to. It’s great if youContinue reading “Postural Drainage”

Aerosol Generating Procedures

The long awaited clarification on aerosol generating procedures for physical therapists and physical therapist assistants has finally dropped! The APTA just released its professional guidelines for what portions of physical therapist and physical therapist assistant care equates to an aerosol generating procedures, therefore requiring increased PPE for procedure performance to ensure clinician safety. On AprilContinue reading “Aerosol Generating Procedures”

The Duet Device

Have you seen an Acapella Duet before? This is another one of those things I wish I could hand out to maybe half of my patients. A Duet device is a special kind of Positive Expiratory Pressure (PEP) that provides resistive oscillatory pressure to exhalation which promotes increased lung volumes due to re-inflation of collapsedContinue reading “The Duet Device”

Bellissimo, G., Leslie, E., Maestas, V., & Zuhl, M. (2020). The Effects of Fast and Slow Yoga Breathing on Cerebral and Central Hemodynamics. International journal of yoga13(3), 207–212. https://doi.org/10.4103/ijoy.IJOY_98_19

Jünger, C., Gaede, K. I., Herzmann, C., Lange, C., Reimann, M., Rüller, S. (2020). Pursed-lip breathing ventilation for the treatment of hypercapnic respiratory failure in COPD. ERJ Open Research. 6: 41; DOI: 10.1183/23120541.RFMVC-2020.41

Jünger, C., Rüller, S., Reimann, M., Krabbe, L., Gaede, K., Lange, C., Herzman, C. (2019). Mechanical non-invasive pursed-lip breathing ventilation for hypercapnic patients with COPD. European Respiratory Journal. 54: PA4237; DOI: 10.1183/13993003.congress-2019.PA4237

Nguyen J, Duong H. Pursed-lip Breathing. [Updated 2020 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545289/

Parisien-La Salle, S., Rivest-Abel, E., Boucher, V. G., Lalande-Gauthier, M., Poirier, C., Dube, B. P., Manganas, H., Morisset, J., Comtois, A. S. (2017). Effect of pursed lip breathing on dyspnea and walking distance in interstitial lung disease: a randomized crossover study. European Respiratory Journal 50: PA2246; DOI: 10.1183/1393003.congress-2017.PA2246

Russo, M. A., Santarelli, D. M., & O’Rourke, D. (2017). The physiological effects of slow breathing in the healthy human. Breathe (Sheffield, England)13(4), 298–309. https://doi.org/10.1183/20734735.009817

Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., & Gemignani, A. (2018). How Breath-Control Can Change Your Life: A Systematic Review on Psycho-Physiological Correlates of Slow Breathing. Frontiers in human neuroscience12, 353. https://doi.org/10.3389/fnhum.2018.00353

Follow @DoctorBthePT on Twitter for regular updates!

Emergency Response Screening

I hope, at this point, you’ve all heard of the FAST acronym for identifying signs of a cerebrovascular accident (aka stroke). My in-laws even have a magnet on their fridge with a great comic strip describing the FAST acronym. I have run in to a couple different versions of it in the last few years, but I’ll give you the basic one so you know what I’m talking about. But, we will also go over some other tools you can have in your arsenal for emergency response screening and I’ll tell you where you can go find even more!


I’m not sure if calling 911 is a skill or not, but I’ve certainly done it enough times that I have the process pretty much figured out. We skip the pleasantries and get straight to the point: Where are you, what’s the situation, who is the caller. DON’T WASTE TIME saying “Hi.” Wait your turn to talk. Use speakerphone so you can follow whatever instructions they give you. And always prioritize symptoms: breathing is always MOST important! You are given a priority number (0 is highest priority – that’s for the not breathing folks). And you NEVER hang up until you are told to do so or EMS arrives. It’s fast. It’s nerve-racking the first few times, but you get used to it (that’s a bit weird to say). If you are in doubt, you have two options: Call the physician and request next steps OR

Emergency response is a basic skill for rehabilitation clinicians and Physical Therapists are skilled to provide first line triage in the case of an emergency. Our specialty is movement: to move someone or not to move someone, and how that movement should be done is a critical part of not only our interventions but also emergency response. Large scale emergencies or single patient emergencies both require this level of clinical decision-making. Thankfully, if you don’t feel like you’re ready to provide that knowledge or skill, there are lots of tools to help you in both small and large scale emergencies.

My best advice: Stay calm, trust your training, and trust your gut. If something feels wrong, it probably is.


Let’s look at the FAST tool we mentioned. This is what really got me started down this rabbit hole of exploring emergency response screening processes. What is fast, easy, and gives me the most information to make the determination of what my next step is? The FAST tool is easy and, well… fast. I don’t have to do much other than look at someone and I know they need emergency help. I also know I need to get that help as fast as I can.

American Stroke Association

Pretty self-explanatory. I’ve had a few significant events in my practice (and outside of my practice!) where I have had to utilize this tool and other tools to assess my patients. I’ll tell you a little about these events so you know when and how to use these tools. I hope you can’t implement them quickly and easily so that, no matter what setting you are in, you can determine the best course of action for your patients, family, friends, or random strangers at your friend’s wedding…


The Stroke Diagnostic Tool

One of my patients in an AFC had a history of middle cerebral artery stroke which is what landed him in an AFC to begin with. One day, I showed up for his visit and he had fallen in the bathroom. The door was locked so couldn’t let me in to help him. His staff was unaware this had happened. As I was talking to him through the door, he told me he was uninjured but couldn’t seem to get up. He was confused and his speech was slurring harder than normal. I knew this because I had established a neurological baseline at my first visit with him.

After the AFC staff assisted me in opening the bathroom door, his symptoms persisted, so I took a set of vitals while calling 911. Although his heart rate was a bit high (he did just fall in the bathroom, after all…), his blood pressure was normal and he did have a slight fever. Upon answering and receiving the required information, the Emergency Dispatcher had me preform a stroke screening. In case you’ve never done this or heard of it, it’s three simple questions:

  1. Can he smile? (this checks for facial droop)
  2. Can he raise both arms equally overhead? (this checks for unilateral paresis/paralysis)
  3. Can he say, “The early bird gets the worm?” (this checks for slurring or other speech deficits)

This is called the Medical Priority Dispatch System (MPDS) Stroke Diagnostic Tool (SDxT), and it is based on research of the FAST acronym for stroke screening. The SDxT has a high specificity (0.96) and a not so impressive sensitivity (0.41). Therefore, this tool is great for ruling in a NEW stroke, but, because my patient already had a stroke with residual deficits, it gave false results. I had to repeatedly interpret the results in comparison to his baseline. I’m sure the dispatcher was really annoyed with me saying, “No more than his baseline,” as an answer to her first two questions. Thankfully, it was only a new UTI and he turned out fine after some antibiotics and inpatient rehab. Because this tool has a specificity of 0.96, though, it is great for ruling in new stroke if your patient presents with these clinical symptoms in any setting.

PT Clinical Decision-Making:
Is this an emergency? Yes, single-patient – needs evaluation s/p fall and for neurological changes, FAST criteria met, SDxT inconclusive
Does this patient need to move? Yes
How should this patient move? Lift assist team from the floor, track-chair up the stairs and out of the house (a chair on tracks that can climb stairs), and by ambulance to hospital


Other Clinical Tools

Another piece of the puzzle needs to be blood pressure. However, like I’ve mentioned many times before, taking a single blood pressure measurement (although better than doing nothing) doesn’t give you much information. You need to have a baseline measurement. The rate of noncompliance with hypertension medication can be anywhere from 40-60% depending on the article you read. So, even if you KNOW your patient has hypertension, that doesn’t mean they’ve been managing it properly. Those medications can have some side effects that people just don’t like (like going to the bathroom too often or symptoms of orthostasis), so people tend to not take them for different reasons. And that’s just the people you KNOW about! We’ve talked about exercise induced hypertension which may be present in just about anyone, and we don’t even really know how best to manage that yet. And then there is the basic fact that you can’t just look at someone and know they have hypertension. Clinical symptoms don’t always present in people who are young and healthy otherwise, and they often are missed. Please take a read in the article about blood pressure basics and dig in to some of the items regarding blood pressure management. We, as Physical Therapists, should be playing a crucial role in this arena. This is my soapbox and I will die on it. Vitals are vital.

Photo by cottonbro on Pexels.com

Blood pressure screening isn’t just useful to identify cerebrovascular accidents! If you take that baseline blood pressure and you know they typically run high, maybe 160/94, you may not be as concerned when you see a 166/94 pop up at your visit today. However, if you have established a baseline 160/94 blood pressure and you see 200/106 show up, now you can make a clinical decision regarding what you need to do next: do some further assessment because you know they run high, call the physician to determine next steps if they are exhibiting no symptoms, or call 911 if they are are in a hypertensive crisis with symptoms.

Unfortunately, if you see 164/90 show up, but you have no baseline to compare to, you may not know what to do. One of my very first patients as a PT student presented with a 164/100 blood pressure one day, but was having many symptoms of something else going on. She did not meet FAST criteria and I had no comparison blood pressure to go off of. I had clinical presentation of something so I called 911. She had a seizure in the Emergency Department shortly after arriving, but turns out she had a history of seizures. Hypertension was kind of like an aura for her. You just never know. If I had taken a baseline blood pressure, I may have had a better idea of what to do with her and not struggled to figure it out until the end of our visit.

PT Clinical Decision-Making
Is this an emergency? I didn’t know because I had no baseline to determine if this was a hypertensive crisis for her and I didn’t know her history of seizures. But, No, it was not an emergency due to her history.
Does patient need to move? Yes, but…
How does this patient need to move? …only to the floor if I would have known her seizure history. I would have called the physician for persistent symptoms and notified them of a seizure if it happened. She could have transferred to the hospital via private car with a driver if necessary depending on the outcome and length of the seizure.

To be very clear: DO NOT DELAY CALLING 911 to take a patient’s blood pressure. If they’ve met the FAST criteria, SDxT criteria, both, or ANY other emergency response criteria, and you haven’t taken their blood pressure yet, call for emergency medical assistance first! Time is literally brain cells. Don’t waste even a second. Like my patient above, even if it isn’t a stroke, they may still need medical attention for some reason. You can take their blood pressure while you wait for EMS to arrive or when the Dispatcher asks you to do it.


And then there is my friend’s wedding…

There I am in a gown at the head table during the reception and down goes someone in the crowd. The medical expertise at the reception included me, an NP student, and an ortho nurse. Not your best emergency response team, but better than nothing, right? I rush over to this mildly responsive man who cannot move and is slurring something and I’m immediately informed by a family member that he has a history of stroke somewhat recently. I observed pretty quickly that he met the FAST criteria so, I call for someone to call 911 because time is brain cells here.

Having no equipment other than my brain, I immediately started the SDxT assessment to save time, but again, because he has a history of CVA, lots of positives show up: heavily slurred speech, inability to raise the left arm, and obvious facial droop (I didn’t have to ask him to smile…). I started a detailed neuro assessment (think acute care-style) with his family member assisting for comparison to baseline and sure enough… exacerbation of symptoms. EMS arrived, I handed off the neuro evaluation outcomes, and off he went.

PT Clinical Decision-Making
Is this an emergency? Yes, single patient – needs evaluation of acute neurological changes, FAST criteria met, SDxT positive
Does patient need to move? Yes, immediately
How does this patient need to move? Yes, lift team transfer to stretcher from floor and by ambulance to hospital


Although these tools are specific to screening for cerebrovascular accidents, the Medical Priority Dispatch System utilizes an algorithm to screen for several emergency medical events. You can take a look at more tools here:

They have emergency protocols for tourniquet use, emergency child delivery, and even active shooter response! There is a section on nurse triage, fire, and many others!


Your clinical knowledge as a Physical Therapist (or other Rehab Clinician) goes a long way, even when other tools can’t give you clear answers. Overall, even though both of these patients were assessed with the same tools, both of them had history of strokes, and both of them gave confounding outcomes, they BOTH required urgent medical care for one reason or another. Having both tools in your pocket gives a higher percentage shot of remembering how to identify the need for emergency response and having a baseline comparison was key for both patients to identify the level of need. Eventually, it was clinical knowledge that determined the cause (not mine, but some very smart provider at a hospital), but it was the initial tools that got the patients the care they needed in time.


Have you used the SDxT or the FAST tool? I’d love to hear your story in the comments!

It’s Getting Hot in Here: Body Temperature

How many times have you had your temperature taken lately? I think I’ve had my temperature taken thousands of times in the last few months. We are seeing the increased use of forehead scanning thermometers and temporal scanners, all the non-contact forms of temperature assessment, to screen folks for COVID-19 symptoms upon entry to anyContinue reading “It’s Getting Hot in Here: Body Temperature”

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References:

Abegaz, T. M., Shehab, A., Gebreyohannes, E. A., Bhagavathula, A. S., & Elnour, A. A. (2017). Nonadherence to antihypertensive drugs: A systematic review and meta-analysis. Medicine96(4), e5641. https://doi.org/10.1097/MD.0000000000005641

Barron, T. (2013). MAKE IT FAST. The Journal of Emergency Dispatch. Retrieved from https://iaedjournal.org/make-it-fast/

Brice, J., et. al. STAT 911: Stroke Assessment Tool for 9-1-1 Dispatchers. https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.108.545574

Buck, B. H., Starkman, S., Eckstein, M., Kidwell, C. S., Haines, J., Huang, R., Colby, D., & Saver, J. L. (2009). Dispatcher recognition of stroke using the National Academy Medical Priority Dispatch System. Stroke40(6), 2027–2030. https://doi.org/10.1161/STROKEAHA.108.545574

Clawson, J. J., Scott, G., Gardett, I., Youngquist, S., Taillac, P., Fivaz, C., & Olola, C. (2016). Predictive Ability of an Emergency Medical Dispatch Stroke Diagnostic Tool in Identifying Hospital-Confirmed Strokes. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association25(8), 2031–2042. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.04.021

Follow @DoctorBthePT on Twitter for regular updates!

PT/INRs: Helping Patients Manage their Anticoagulation

So, who’s up for some bloodwork? Venipuncture, anyone? Finger prick, maybe? No..? Oh… Well, ok then. I’ll carry on. I know it may sound a bit crazy, but as a PT, I actually do some (very) minor blood work. I’m not trained as a nurse or phlebotomist or anything like that. Nope. Just some on-the-job-training on doing PT/INRs.

In this case, PT doesn’t stand for Physical Therapist like it usually does in things I write and across the medical spectrum. In this case, PT stands for prothrombin time (or “protime”) and INR stands for international normalized ratio. These factors combine to tell us many things about the effectiveness fo anticoagulant therapy. And, I’m sure you guessed it, they are important for us, as rehab clinicians, to do our best work for our patients. A normal INR in a patient who is not pharmacologically anticoagulated is 1.0. When we are pharmacologically anticoagulating, we want the INR to be between 2.0 and 3.0 and I have even been asked to go up to 3.5 for certain patients with multiple risk factors or who have mechanical heart valves. Average PT is 10-14 seconds.

IF you find that INR is greater than 5.0, you should NOT be performing any kind of therapeutic intervention and you should NOT be exercising the patient. Obviously, they will need to move enough to access care, and they should do so safely, maybe even with your help to prevent falls, but outside of that, they are inappropriate for therapy. If you find an INR higher than 6.0, the patients needs to get immediate medical attention as they are at an unsafe risk of bleeding. If you find the INR is too low, mobilization helps with blood flow which decreases clotting, so you should be working to mobilize the patient as much as you can in the absence of signs and sympyoms of DVT or PEs. However, you will still need to contact the physician as the patient may need adjustments in their anticoagulant dosage.


Doing this is actually really easy. We use a small meter called a CoaguCheck. Some patients have their own but I carried one regularly because I did so many of these. A small finger prick is done with clean technique, a capillary chip is inserted in to the machine, the blood is placed on the capillary chip, and a reading appears. There are several more pieces to this because the machines can be VERY finicky. The biggest issue is usually getting blood! I’ve put some serious time in to managing an arm from proximal to distal in an effort to “milk” blood to the finger to make sure I can get enough.

The best tip I ever received in performing this procedure is that you need enough blood to make it looks like a lady bug is sitting on the finger. This needs to be significantly more blood than what is required for blood glucose monitoring. I know that doesn’t sound like a lot, but if that blood is not therapeutically coagulated, it can be really difficult to get that much in the amount of time you are given. That’s the other hard part, the machine gives you a countdown in which you must apply the blood to the capillary chip. If you run the timer down, you have to start over with a new finger prick, new chip, and new reading.

Roche Diagnostics CoaguChek XS System Coaguchek XS System:Healthcare
Source

I typically go at this in a specific way each time: getting everything set up with clean technique, then get the chip, machine, and lancet ready. I then start my timer (which happens when you insert the capillary chip in to the meter) and spend about half the time (90 seconds) working the arm, hand, and finger to make sure I am going to get enough blood. Then I clean the finger, lance it, and “milk” enough blood out to look like a lady bug is sitting on the finger. Finally, I apply the capillary chip to the blood, allow capillary action to do its thing, and then wait for my reading.


Especially after a surgery, many of our patients are on prohpylactic anticoagulant therapies to reduce their risk of developing blood clots that could be potentially fatal if they travel throughout the circulatory system and relocate themselves in the lungs. But post-operative patients are not the only ones I help with this minor technique. As many of you know, I manage many patients with complex chronic diseases that require them to be heavily anticoagulated. These conditions may include heart failure with atrial fibrillation, cancer when chemo effects to the heart, or they have hypertension, diabetes, and Factor V Leiden deficiency. There are a million combinations I could list here. Regardless, most of them end up on Coumadin/Warfarin for anticoagulation which means their PT/INRs have to be monitored for therapeutic effect.

Now, of course there are other options for long term anticoagulation, such a rivaroxaban (Xarelto) or apixaban (Eliquis). These have some serious benefits like not having your finger pricked weekly to monitor your PT/INR, not having to worry about dietary choices (see below), and having fewer drug-to-drug interactions. However, when you have a patient with a history or high risk of falls, you don’t really want them on these particular options. Even though the effects wear off sooner, once the anticoagulant is in effect, it cannot be reversed. Once you start bleeding, you keep bleeding. That’s a real concern when you develop a subdural hematoma from a fall.

Photo by Karolina Grabowska on Pexels.com

Another drug in this “new” class of anticoagulants is Dabigatran (Pradaxa). I listed this one separately because a clotting antidote has actually been developed called idarucizumab (PraxBind). However, Pradaxa can still be hard on kidney function and tends to be incompatible with mechanical heart valves, similar to the other drugs in the “new” class of anticoagulants.


Things to watch out for when you have a patient utilizing Coumadin/Warfarin (outside of the obvious bruising/bleeding) include:

  • Medication Interactions. All generally administered medications included
    • Products containing acetaminophen
    • Most broad spectrum antibiotics
    • Aspirin
    • all other NSAIDs
    • Most antacids and laxatives
    • Antifungals
    • Amiodarone (or other rhythm drugs)
  • Supplements. Just don’t. There are many interactions with various supplements and they are not well controlled or easy to treat.
  • Foods. Anything high in Vitamin K. This means all leafy green and dark purple vegetables and fruits. This also means green tea. Like I mentioned above, Vitamin K is the antidote to Coumadin bleeding, so eating foods with higher levels of vitamin K will decrease the effectiveness of the drug.
    • Other foods include grapefruit, cranberry, garlic, and black licorice
  • Alcohol. Alcohol is also a blood thinner so you don’t want to double down on the effects of the medications.

Also, be on the lookout for bleeding that isn’t obvious. This can be GI bleeding, subdermal bleeding, internal bleeding, or cranial bleeding which would result in:

black or coffee-grounds stool or vomit
bleeding of the gums when brushing teeth (not otherwise explained)
severe head aches or stomach aches
dizziness, weakness, fatigue
low HgB and low Hct on CBCs
shortness of breath with minimal activity or at rest
new onset or increase in falls
ecchymosis of an entire limb or quadrant

All of these things would warrant immediate evaluation by a medical physician, probably in urgent care or emergency depending on the severity. Patients may need to receive the Coumadin antidote, Vitamin K or PCC.


Photo by Daria Shevtsova on Pexels.com

Other considerations include the need for dietary support. Call in a consult to your dietician because these folks aren’t going to be able to eat much from a large class of foods that would otherwise be REALLY good for them. It’s not that people who take Coumadin/Warfarin CAN’T have foods with vitamin K, but they have to eat about the same amount every day to keep the blood levels steady. Spikes in the amount of Vitamin K people eat are what causes problems with their anticoagulation therapy. And, given we are basically asking people to limit a large category of foods that are otherwise REALLY healthy, people who take Coumadin/Warfarin are going to need some serious dietary support to avoid adding obesity to their list of medical conditions.


So, who’s up for picking some fingers? It’s a great easy may to help patient’s manage their chronic conditions in the home, on the go, or in a short amount of time. Expanding your role and fulfilling your scope is only going to help your patients be their best selves and make their best choices.


How about you? Do you do anything in your practice that is something you learned on the job but not otherwise part of your standard professional practice? Tell me about it in the comments!

More Reads on Chronic Disease Management…

Rule of 2’s

So today, we are going to focus on the role PTs and PTAs need to be filling in the treatment and management of congestive heart failure. The first thing you need to address is the rule of twos. Don’t assume someone else had ever educated your patient about this. I cannot tell you how manyContinue reading “Rule of 2’s”

References:

Collins, S. & Beckerman, J. (2016). How Do New Blood Thinners Compare to Warfarin? Retrieved from https://www.webmd.com/heart-disease/atrial-fibrillation/features/warfarin-new-blood-thinners

Mayo Clinic. (2020). Prothrombin time test. Retrieved from https://www.mayoclinic.org/tests-procedures/prothrombin-time/about/pac-20384661#:~:text=In%20healthy%20people%20an%20INR,in%20the%20leg%20or%20lung.

Wax, E., Zieve, D., Conaway, B. (2019). Vitamin K. Medline. Retrieved from https://medlineplus.gov/ency/article/002407.htm

Follow @DoctorBthePT on Twitter for regular updates!

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It’s Getting Hot in Here: Body Temperature

How many times have you had your temperature taken lately? I think I’ve had my temperature taken thousands of times in the last few months. We are seeing the increased use of forehead scanning thermometers and temporal scanners, all the non-contact forms of temperature assessment, to screen folks for COVID-19 symptoms upon entry to any public space. Are you taking temperatures in your PT clinic? I hope so. It’s not a perfect assessment, but it’s better than nothing and at least gives the appearance of attempting to create a safe patient environment.

There’s a few considerations for temperature that can be really relevant to PT practice outside of just making sure your patients don’t have COVID-19. That’s right, ya’ll! We are going back to our old friend, Sepsis. We talked about sepsis in quite a few posts in the past, and it keep rearing it’s super ugly head in so many topics. You may be thinking, “Doctor B, I really don’t see that many patients with sepsis, so I’m not sure where you are going here…” I may be the odd one out, but I’ve seen too many patients with sepsis. Even one is too many, but I’ve seen far too many. I wouldn’t challenge you that, depending on your setting, you’ve probably seen more patients with sepsis than you realize. If you are in general acute care, skilled nursing, or home care, sepsis is everywhere, but it takes on different names, usually the names of the infectious entities that cause it.

Photo by Andrea Piacquadio on Pexels.com

I’m sure you’ve heard of all the infections that land people in the hospital for “pneumonia”, clostridium difficile (c. diff), MRSA, VRSA, “staph”, etc…… All of these land people in the hospital because they have, to some point, gone septic, meaning the pathogens have entered the blood stream (aka bacteremia, septicemia, blood poisoning) making them far more difficult to fight off without help. But, as PT’s how do we detect sepsis? If you read the headliner on this article, you should probably have an idea of where I’m going.

Detecting sepsis and other infections is a top priority job for PTs and other rehab professionals. He look for signs and symptoms of infection all the time, from redness and swelling to exudate and smell. But infections can be so much more subtle than that. And sepsis can be hidden.

The Basics

Remember that human beings can only function properly in a certain homeostatic environment. Just like our pH range is so small (7.35-7.45 ideal range), our temperature range is also pretty narrow: 96.0 F to 100.4 F. Obviously, that doesn’t mean we can’t somewhat function outside of these parameters, but the function is not ideal.

That’s right, normal temperature is a range. It’s not just 98.6 F. That’s because “normal” depends on where an dhow the reading was taken. Temperature can be taken at any of the following locations, but be sure to document the location as there are different “normal” temperatures for each location.

  • Oral/Sublingual
  • Temporal
  • Ear
  • Axillary
  • Forehead
  • Rectal
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Not to say that any one is better than the other as they all have their clinical place, but some are more accurate. However, it may be significantly difficult to get an accurate oral temperature on a screaming infant. And most adults will shy away from a rectal thermometer. So, even though they differ in accuracy, they can all be useful. Clearly, even though forehead scanning is one of the least accurate, it has its place in the new “contact-less” environment in which we function.

Hypothermia

So, what if a body temperature is below 96.0 F? Remember that body temperature elevates to ward off invaders. It is part of our body’s immune response. If the temperature doesn’t respond to invaders, the body is NOT fighting. Sometimes, the temperature can even decrease. I have actually had a patient where a sublingual temperature of 95.2 F was his only symptom of sepsis because his body was NOT fighting the infection and we caught it early. A decline in body temperature can happen for a number of reasons:

  • Advanced age resulting in less efficient immune function
  • Multiple infections overwhelming the immune system
  • Overload of antipyretic medications (acetaminophen, ibuprofen, some antihypertensives…)
  • Certain genetic conditions (Prader-Willi Syndrome)

Consequently, the list ofd things that makes someone more susceptible to septic infections looks pretty similar with the addition of:

Hyperthermia

AKA Fever. However, hyperthermia can happen for reasons other than infection such as with heat stroke. This is also something we need to be monitoring in our patients as we may be asking them to physically exert themselves, whether in our presence or not, through exercise on a hot day. We may also see patients who have a host of thermoregulation conditions that can be caused by:

Remember that an elevation in body temperature is a response to an infectious agent of some kind. Invaders tend to only be able to live in certain environments so the body elevates the temperature to change the environment and make it unfavorable or uninhabitable for the invader. Elevation of body temperature can also happen in the evenings as your body begins its “clean-up” process. However, most medical professionals don’t consider elevated body temperature to be febrile until it is 100.5 F or greater.

Clinical Application

If you are taking a full set of vitals anyway, blood pressure, heart rate, oxygen saturation, you may as well take a temperature, too. Especially right now, temperature matters and is important to our fully informed treatment of any patient. However, if you have someone who is post-operative of ANY KIND, you should be taking their temperature at your visits. We are the front line against infections in our post-operative patients.

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And in our treatment of populations on either end of the age spectrum, we need to constantly be putting sepsis on the list when we consider our differential diagnosis. I’m not saying it needs to be front and center, butI’m not saying it shouldn’t be, either, especially given the pandemic climate. This also then feeds in to the ongoing screening of people for COVID-19 and other infections that we discussed HERE.


How many COVID-19 screenings have you done in the past week? Tell me in the comments!

Sternal Precautions

“Patients exchanging habits of activity for complete rest are likely to become rapidly worse.” This quote fuels my everyday. These words have informed nonsurgical and surgical rehabilitation and its evolution from handing out bed rest like Oprah hands out cars to getting people moving early and keeping them moving often. Here’s the crazy thing: ThisContinue reading “Sternal Precautions”

Diaphragmatic Breathing

Let’s talk about this super simple technique that can change everything. Diaphragmatic breathing is really just how we are all supposed to be breathing most of the time. The purpose of the diaphragm is to facilitate breathing. Diaphragmatic breathing improves gas exchange and increases lung volumes. These are all really good things if we need toContinue reading “Diaphragmatic Breathing”

I’ll Huff and I’ll Puff… But the Huff Will Be More Effective

What is a huff? Huffing is one of the more difficulty techniques to learn for airway clearance. I find that most of my patients have trouble mustering the strength to perform a good solid huff. It’s not just that it is unfamiliar, but also that it takes diaphragm strength that they just don’t have. ButContinue reading “I’ll Huff and I’ll Puff… But the Huff Will Be More Effective”

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References

CDC. (2020). Sepsis. Retrieved from https://www.cdc.gov/sepsis/what-is-sepsis.html

HealthWise Staff. (2019). Fever Temperatures: Accuracy and Comparison. C.S. Mott Children’s Hospital, University of Michigan Medicine. Retrieved from https://www.mottchildren.org/health-library/tw9223

Skelton, F. (2016). Rehabilitation of Central Nervous System Disorders: Impaired Thermoregulation. American Association of Physical Medicine and Rehabilitation. Retrieved from https://now.aapmr.org/impaired-thermoregulation/

Follow @DoctorBthePT on Twitter for regular updates!

COVID-19: Where the Heck Are We?

I started this venture back in March in response to COVID-19. I saw many Physical Therapists and other rehab professionals shutting their doors because it wasn’t safe to keep them open. I saw an opportunity to improve our profession by addressing a deficit in practice: the lack of cardiopulmonary skill implementation. It wasn’t even that we didn’t have the skills, because we absolutely do! We learn all this stuff in school and sometimes its just a matter of how much you practice it. Implementation has always been my concern. We have tons of research saying all the best things about exercise, but we don’t implement most of it. Implementation is key. So, I was really just hoping to help people brush up on things they already knew or apply them in different ways so they could keep working and keep practicing even in the midst of a global pandemic.

Along the way, this process became complicated because what we all knew as fact was changing. The view of “science” changed. Lots of things changed. The organizations we thought we could rely on failed us. And, to the entire medical world still practicing, we felt like every day, sometimes every hour, was a slap in the face. COVID-19 sure has made an impact on the world, but I can’t even begin to explain the impact it’s had on the medical community.

So, where does that leave us? COVID-19 is still here and we are still treating it, so let’s take a look at some data on where we are at in this thing.


All the Numbers and Changes Over Time

I hate this part. There are a lot of different data sources to use here. All of them will be different due to different reporting metrics and time frames. So don’t be surprised if all the numbers aren’t EXACTLY the same. There are also different ways to combine, separate, and read the data, which also creates differences in numbers. We are going to go with the data from Johns Hopkins University of Medicine. Why? Because they run one of the largest live updated databases of this information that draws from several other databases. Say what you want, I’m going with the largest amount of information aggregated by the leading professionals.

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At the time of writing this: Global Cases are at 24,563,393. The US has over one fifth of those at 5,901,393. Global deaths are at 833,466. The US has contributed 181,409 of those. Global recovered cases are 16,051,454. The US has contributed 2,101,326 of the recoveries. Total tests performed in the US is at 75,301,306. And the number of hospitalized patients in the US is 365,993.

Lots of number, I know. But we are just going to do some simple things with them. And, for some reason, people seem to want the numbers of COVID-19. They have never mattered before when millions were dying of flu or tuberculosis or malaria but whatever…

These numbers tell us that there are still 7,678,473 people in the world actively suffering from COVID-19 (number of total cases – recoveries – deaths = ongoing cases). This may not include the long-haulers which are usually viewed as “recovered” even though they would sorely disagree. In the US, that leaves 3,618,658 people (about half of the world total) still fighting COVID-19, or just over 1% of the population of the US. I know 1% doesn’t sound like much, but when you know that 1% is more than three and a half million people, that 1% looks pretty big to me.

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We also need to understanding that all of these numbers are an underestimation of the actual picture. We can’t count any cases that happened before testing because we didn’t have testing to prove there were positive cases! So all the cases that happened back in February and March (and some even earlier, researchers are now finding) didn’t make the count. That includes positive cases, deaths, hospitalizations, and recoveries. Doctors at that time were treating COVID-19 based on severity of symptoms, imaging studies, and based on exclusion criteria. We also need to remember that testing has been pretty restricted in the grand scheme. Even if you’ve had an exposure, you can’t be test until you show symptoms, which doesn’t prevent you from spreading it around for a few days first. And, for a while, there were so few tests that only those at highest risk were every tested. So, many cases went unreported.

That’s a lot of numbers… Glad that’s over…


What else is going on?

Symptoms of COVID-19 can range from all the typical symptoms of a respiratory virus (coughing, fever, shortness of breath) to GI symptoms (nausea, vomitting, dehydration) to strange presentations like wounds on the toes. Neurological symptoms are well know to be involved such as confusion, loss of smell or taste sensations, or a headache. Serious presentations may include blood clots, strokes, heart attacks, acute respiratory distress, or altered mental status. It all depends on where the infection takes hold in your body and what the mechanism of entry was. Speaking of how someone gets infected…

We are still experiencing a PPE shortage. And providers who experienced a PPE shortage are more likely to have been infected with COVID-19. N95s are still the most frequently reported shortage item, but even gloves are beginning to be in short supply. Even with the PPE shortage, though, health care providers who wore a mask at every clinical interaction were less likely to contract COVID-19. Healthcare Providers still rank among the highest risk people to contract COVID-19.

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Although the CDC maintains its stance on COVID-19 only being transmitted through droplets (aka droplet precautions), many research studies have determined that COVID-19 is airborne. The WHO has also acknowledged that there is significant evidence to support the likelihood of airborne transmission. Even many employers have acknowledged that their providers at at an increased risk and provided the supplies necessary for airborne precautions. As if things weren’t already confusing enough, even though the CDC maintains their stance on droplet precautions, they recommend airborne precautions when performing aerosol-generating procedures. Thankfully, many professional organizations have come forth to define “aerosol-generating procedure” to help guide treatment safety.

A large field of research has been devoted to determining the ventilation and air purification needs that rooms of different sizes and capacities would require. Healthcare engineering in many capacities, from 3D printing shields and N95s to improving sanitization to HVAC updates, have been working overtime to fuel the needs of providers and patients.

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Long haulers have emerged. These are the folks, whether hospitalized for COVID-19 or not, that continue to experience symptoms of COVID-19 long after the standard infection and illness window. Some people who believe they were infected back in February before testing was even available, are still experiencing the fatigue, shortness of breath, and muscle aches that resulted from their infections.


Have we made any progress? What are we doing about this?

The medical world and the non-medical world have started to blend together, for better and for worse. Post-Intensive Care Syndrome (PICS) has been making headlines and the therapy world (including respiratory therapists) are getting some serious spotlight. The world has become aware of the fact that people don’t just jump back from serious diseases. Proning, an intervention that has been around for a long time, has also been given screen time. These particular topics have placed rehabilitation front and center. Considering most people don’t even know what PTs and OTs do, and think SLPs just play mind games all day, I’d say we’ve made some positive public image impact.

Some professional organizations are also stepping up and providing toolkits, new tools, and educational content regarding treating patients with COVID-19. There is also guidance issued regarding screening for COVID-19 in the outpatient setting to decrease transmission and infection risk.

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Like the numbers above have shown, over 2.1 million people have recovered and therapy played a pretty big role in helping some of those people recover. The early numbers from back in May showed that about 20% of the people who contracted COVID-19 would require extra medical help to recover, and about 10% (half of the 20%) would need long term inpatient care. We’ve gone from dreading the intubation and ventilation phase to seeing many of these people in the home and outpatient settings for treatment, management, and recovery. Outpatient clinics have reopened and begun utilizing technology to help more people than ever!

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Telehealth is the biggest win to come from COVID-19. The implementation of telemedicine into the therapy world used to be a pipedream. It was only for expensive, private-pay therapy. Today, most payers reimburse for telehealth visits to some extent. We can now provide follow ups, evaluations, check ups and check ins, virtual home programs, and so many other services to our patients without have to risk their health or our own. If anything about COVID-19 sticks around for the better, I hope it’s telemedicine for the rehab world. Thankfully, CMS has indicated that they have no intention of repealing the telemedicine reimbursement program. That’s really great because these long haulers are needing long curses of therapy and many others who were hospitalized are needing frequent and long term rehabilitation for severe deconditioning and pulmonary function impairments.

Research has indicated that the suspected time frame that COVID-19 will significantly impact our lives in 18-24 months. The research on immunity from previous infections is mixed with some people showing antibodies long term and some people not showing any antibodies to the infection after a known case. Herd immunity has been discussed as a solution, but that can’t happen is antibodies don’t stick around enough. Not to mention it would require over 1,000,000 MORE deaths to achieve than what we currently have. Not quite an acceptable solution. Vaccines are all in the works from multiple different companies in a race to the cure. From a rehab perspective, we need to be screening every patient. We have the abilities, skills, and knowledge to do so. You can read more about that here.


Overall, our world has completely changed, at home and at work. COVID-19 doesn’t look like it’s going away anytime soon. The SARS-CoV-2 virus has definitely mutated over time with more than 6 different strains already detected. The acuity of illness seems to be decreasing, but the symptoms seem to be lasting longer. It will probably continue to do so. I hope this somewhat brings you up to speed to where we are now. I’ll keep updating you on big changes. And I’ll keep helping you update your skills to best treat your patients, COVID-19 or not.


Are you still experiencing PPE shortages at your workplace? Tell me about it in the comments!

Vibration & Percussion

If you read my post on airway clearance techniques, you probably saw vibration and percussion down at the bottom of the force progression. Although I have covered several other pieces of the force progression (Active Cycle of Breathing, PEP Devices, etc) in subsequent posts, I haven’t touched on these topics yet because they haven’t beenContinue reading “Vibration & Percussion”

More Than Just A Respiratory Disease: The Tools You Need to Rehab COVID-19

Isn’t COVID-19 just a respiratory disease? If only that was true. We are good at treating respiratory infections. We have lots of drugs for viral, bacterial, parasitic, and fungal infections of the lungs. Most of them work really well! We also have several back-up treatments, inhaled medications, and adjuvant therapies (like rehab!) that make primaryContinue reading “More Than Just A Respiratory Disease: The Tools You Need to Rehab COVID-19”

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Resources:

CDC (Updated August 12, 2020). COVID-19 Overview and Infection Prevention and Control Priorities in non-US Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html#:~:text=COVID%2D19%20is%20primarily%20transmitted,be%20inhaled%20into%20the%20lungs.

Dong, E., Du, H., Gardner, L. (2020). An interactive web-based dashboard to track COVID-19 in real time. The Lancet: Infectious Disease: CORRESPONDENCE 20(5):533-534. DOI:https://doi.org/10.1016/S1473-3099(20)30120-1PlumX Metrics.

COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). https://coronavirus.jhu.edu/map.html

Self WH, Tenforde MW, Stubblefield WB, et al. (2020). Seroprevalence of SARS-CoV-2 Among Frontline Health Care Personnel in a Multistate Hospital Network — 13 Academic Medical Centers, April–June 2020. MMWR Morb Mortal Wkly Rep. DOI: http://dx.doi.org/10.15585/mmwr.mm6935e2external icon

Other resources can be found on the linked pages to which they apply.

Follow @DoctorBthePT on Twitter for regular updates!

Sternal Precautions

“Patients exchanging habits of activity for complete rest are likely to become rapidly worse.”

This quote fuels my everyday. These words have informed nonsurgical and surgical rehabilitation and its evolution from handing out bed rest like Oprah hands out cars to getting people moving early and keeping them moving often. Here’s the crazy thing: This quote was said by Austin Flint in 1886 in specific reference to the rehabilitation of patients with heart disease. 134 years later, we are still fighting the battle against overly-restrictive precautions and rest orders across all disciplines and diagnoses.

I don’t know if you are aware of how a sternotomy goes down, but it’s pretty aggressive. There is a lot of tissue stretching, stabbing (yes, literally), cutting, burning, and wiring. And then there’s the retractors. Those babies get in that tiny space and make it so much larger! No wonder patients are sore afterward. You can go watch a video on YouTube to see what it’s all about. Patients typically have discomfort in their thoracic and cervical spines, shoulders, ribs, anterior superior chest and joint articulations… and that’s just for a standard valve replacement! If you add a CABG, we can add peripheral wounds in the arms and legs, and if we are talking organ replacement, the back of the head, low back, and hips can get pretty sore from positioning and the use of a bump to help open the rib cage.

Even though the first coronary artery bypass graft (CABG) wasn’t performed for the treatment of heart disease until 1960, infection and dehiscence of the sternotomoy were relatively common (not terribly surprising considering what goes in to it!). Of those who experienced these complications, up to 50% died. Needless to say, surgeons felt like they needed to get extra cautious. However, there was never any research performed to discern which movements of the body or extremities stressed the sternum the most, and whether or not this stress impaired healing. Thus, sternal precautions were laid down.


There is NO set standard for sternal precautions

Yup. Different surgeons, medical centers, and states all do it differently. There is also no set standard for when or how to reduce or remove sternal precautions. In the heart and lung transplant arena, our surgeons and facilities tended to decrease sternal precautions over time, allowing one or two upper extremity movements every month or so and decreasing the weight lifting restriction by 5-10 pounds every month or so. Real consistent, right? For further evidence of these inconsistencies, check out this table which shows you three different sets of “sternal precautions” from three different major medical centers.

source

And to complicate matters even further, many post-operative exercise prescriptions often involve a standard set of exercises, many of which violate one or several sternal precautions that are initially given! I’ve found this to be true at more than one location! One survey performed in 2011 found more than 28 different versions of sternal precautions! And, to add one more level of complication, Physical Therapists and Cardiothoracic Surgeons do sternal precautions very differently.

Top 5 sternal precautions prescribed by cardiothoracic surgeons:
  1. Lifting no more than 10 pounds of weight bilaterally
  2. Lifting no more than 10 pounds of weight unilaterally
  3. Bilateral sports restrictions
  4. No driving
  5. Unilateral sports restrictions
Top 5 sternal precautions reported by physical therapists in order of importance:
  1. Lifting no more than 10 pounds of weight bilaterally
  2. No hand over head activities bilaterally
  3. Bilateral sports restrictions
  4. No driving
  5. Active bilateral shoulder flexion no greater than 90°
And ACSM tells us this:

For 5 to 8 weeks after cardiothoracic surgery, lifting with the upper extremities should be restricted to 5 to 8 pounds (2.27-3.63 kg). Range of motion (ROM) exercises and lifting 1 to 3 pounds (0.45-1.36 kg) with the arms is permissible if there is no evidence of sternal instability, as detected by movement in the sternum, pain, cracking, or popping. Patients should be advised to limit ROM within the onset of feelings of pulling on the incision or mild pain.


There has been some limited research that showed that pushing up from a chair during sit to stand activities provided the greatest physical stress force to the sternum. However, these patients had known chronic sternal instabilities, so the cases are slightly different. Even though the stress has been measured to be physically less, unilateral loaded arm movements caused the greatest pain in these patients. Clinically, I have seen this to be the case. Unilateral upper extremity loading, such as when laying on the side or reaching for a cup of coffee, always seems like the most painful things.

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Take notice, there is nothing in any of these discussion on sternal precautions that mentions splinting the sternum. For as many years as I remember, including before I was a therapist, we have used nice heart or lung shaped pillows to splint the sternum during coughing or sneezing. If the pillow wasn’t available, we taught patients to splint their sternum with their hands or a different pillow. I even took to educating patients about their first sneeze and being ready. That stuff doesn’t show up anywhere in here.

Speaking of a sneeze, there was a study published in Thoracic Cardiovascular Surgery that stated the force across the sternum with a single cough is greater than that measured lifting 40-pound weights. The authors had serious concerns about the lack of surgeon confidence in their owns repairs if the sternotomy couldn’t support 5 pounds of force.

And, we need to talk about the biggest elephant in the room…

Driving. Everyone’s first question after they get home is, “When can I drive again?” There is absolutely no standard recommendation for this one, either. Some physicians say 3-4 weeks once they’ve had their follow-up visit, whereas some say 6-8 weeks. Some patients have been told to lay in the back seat or not wear a seatbelt when they are traveling in a car! These are just generally not safe recommendations from any provider, considering there is a long history of research telling us that wearing a seatbelt and using an airbag decreases the risk of a driver’s sternum contacting the steering wheel. Are we concerned about the patient being in an accident? Sure! But you can’t control everything. The research shows us that there is no higher risk of sternal fracture after a healed sternotomy than if there was no sternotomy.

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So what do we actually know?

What we know from the most recent research is that sternal precautions don’t matter. There, I said it. I spent years teaching other therapists about sternal precautions, all the while thinking, “why do we do this to ourselves and our patients?”

What actually matters is allowing patients’ pain or discomfort at their sternum to guide their movements. A randomized multi-center single blinded study showed that there was absolutely no difference in physical, kinesphobic, pain, or quality of life outcomes and no increased rate of complications when patients were simply asked to just let their post-operative discomfort guide their movement.

“There is no universally accepted definition causing application of SP [sternal precautions] to be largely arbitrary.”

Cahalin, et al. 2011

As far as driving goes, after sternotomy, only minimal forces on the sternum were found with the activities of driving. We actually have found that the safest place in the car for the patient to be is in a seat with an airbag and wearing a seat belt. Whether that is a front passenger or a driver is unclear. Not only does the ability to drive have a huge impact on quality of life, but the lack of driving ability restricts patients from participating in cardiac rehabilitation programs because they can’t get there!

Now, of course, there are wonderful home care therapists to help with this, but they are not always available in all areas and many can’t provide standardized sub-maximal and maximal exercise tests because those require a treadmill or exercise bike and EKG monitoring. So, patients end up having to sit at home, not rehabbing for up to 8 weeks. That’s 8 weeks that they are not only losing muscle mass, aerobic capacity, and functional ability, but 8 weeks that they are NOT working toward improving any of those things like they could in Cardiac Rehab! That’s 16 total weeks of lost time in the recovery from one procedure, simply because the patient couldn’t drive.

Photo by Andrea Piacquadio on Pexels.com

Of course, not all patients are appropriate to drive after having an open-heart related procedure, but evidence shows us that if they are tolerating their medications well and aren’t having persistent arrhythmias, they should be cleared to drive as soon as they are able. I will say, though, that having seen many patients at home for a PT evaluation after open-heart surgical procedures of all kinds, I’m typically pretty glad we got to do a home-based session. Many of them need education on positioning for sleep, infection control, and activity guidelines. You all know by now that I’m a pusher so I always work these people pretty hard. But, you know what? They all got better and there were never any negative outcomes associated with exercise or activity participation. Darn… Should have done a retrospective study on that one…

So what’s the answer? Some authors have suggested a graded approach to precautions instead of the standard blanket precautions laid down on everyone for the same procedures. Some authors have suggested letting discomfort be their guide and allowing any activities and movements that are not placing the patient at a significantly increased risk of nonunion. Some authors have suggested only giving some kind of patient-specific sternal precautions to those patients who are already at higher risk of nonunion due to other comorbidities (such as diabetes or osteoporosis).

Overall, most of the rehab-focused research on sternal precautions has found that they are overly-cautious, restrictive instead of cautionary, and impede physical rehabilitation, which we know is so desperately needed by many after these procedures.


What are the sternal precautions at your facility? Do different doctors give you different precautions? Tell me more in the comments!

A Public Service Announcement: The Chain of Infection (and How YOU Can Break It!)

This post is written for one and all. If you are not a rehabilitation or medical professional, please read this post. Even if you are, please read this post. I’m going to address some things that need clarification. You can have all the opinions you would like, but there are some things that are justContinue reading “A Public Service Announcement: The Chain of Infection (and How YOU Can Break It!)”

Open Heart, Open Mind… Learning About Amio-Loading

I’m always learning something new. I called the cardiologist after an evaluation to report some severe orthostatic hypotension and the nurse and I got to talking. She was going back through the patient’s history and looking for why this may be happening. I had just finished assessing the patient in their home and they wereContinue reading “Open Heart, Open Mind… Learning About Amio-Loading”

Blood Pressure Basics

Are you taking the blood pressure and heart rate of EVERY patient you see for a new evaluation? How about for every visit? A recent survey of over 1800 Outpatient PTs showed that although 51% of PTs reported that over half their caseload had risk factors for hypertension and cardiovascular disease, only 14% of themContinue reading “Blood Pressure Basics”

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Resources:

Balady, G.J., Ades, P.A., Bittner, V.A., Franklin, B.A., Gordon, N.F., Thomas, R.J., Tomaselli, G.F., Yancy, C.W., American Heart Association Science Advisory and Coordinating Committee. (2011). Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation. 124(25):2951-60.

Cahalin, L. P., Lapier, T. K., & Shaw, D. K. (2011). Sternal Precautions: Is It Time for Change? Precautions versus Restrictions – A Review of Literature and Recommendations for Revision. Cardiopulmonary physical therapy journal22(1), 5–15.

Crabtree TD, Codd JE, Fraser VJ, Bailey MS, Olsen MA, Damiano RJ. Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center. Sem Thorac Cardiovasc Surg. 2004;16:53–61.

El-Ansary D, Waddington G, Adams R. Relationship between pain and upper limb movement in patients with chronic sternal instability following cardiac surgery. Physiother Theory Prac. 2007;23(5):273–280.

Gach, R., Triano, S., El-Ansary, D., Parker, R., & Adams, J. (2019). Altering driving restrictions after median sternotomy. Proceedings (Baylor University. Medical Center)32(2), 301–302. https://doi.org/10.1080/08998280.2018.1551298

Katijjahbe, M. A., Granger, C. L., Denehy, L., Royse, A., Royse, C., Bates, R., Logie, S., Nur Ayub, M. A., Clarke, S., & El-Ansary, D. (2018). Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy (‘SMART’ Trial): a randomised trial. Journal of physiotherapy64(2), 97–106. https://doi.org/10.1016/j.jphys.2018.02.013

Knobloch, K., Wagner, S., Haasper, C., Probst, C., Krettek, C., Otte, D., Richter, M. (2006). Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims. Ann Thorac Surg. 82(2):444-50.

McGregor, W.E., Trumble, D.R., Magovern, J. A. (1999). Mechanical analysis of midline sternotomy wound closure. J Thorac Cardiovasc Surg. 117(6):1144-50.

Parker, R., Adams, J.L., Ogalo, G., et al. (2008) Current activity guidelines for CABG patients are too restrictive: a comparison of the forces exerted on the median sternotomy during a cough vs. lifting activities combined with valsalva maneuver. Thorac Cardiovasc Surg. 56(4):190–194.

Pratt, J.H. (1920) Rest and exercise in the treatment of heart disease. South Med J. 13:481–485.

Follow @DoctorBthePT on Twitter for regular updates!

Dehydration

Gosh, this is a fine line… Especially in the patients I regularly see. A colleague and I often say, “If you have any more water, you’ll die. If you don’t have any more water, you’ll die.” This is actually a frequent education topic that I cover with patients. Scary? Yes, but true. So, why is a Physical Therapist going to talk to you about dehydration and water intake? I cannot even begin to explain to you in any short way how important this is to my DAILY practice.

Symptoms of dehydration include:

  • dizziness
  • light headedness
  • low blood pressure
  • orthostatic hypotension
  • increased thirst
  • fatigue
  • confusion
  • falls
  • urinary tract infections
  • incontinence
  • lack of sweating (in severe cases)
  • loss of consciousness (in severe cases)
  • cardiac arrhythmias (in severe or chronic cases)
  • loss of thirst (in severe cases)
  • the list goes on…

I treat all of those things as symptoms of other conditions and some in isolation. I bet you do, too!

Acute, chronic, or severe dehydration results in hypovolemia, which means that your body doesn’t have enough volume (blood volume) to support normal function. Guess what, folks? Blood pressure is a function of blood volume. So, if you lose blood volume, you will also lose blood pressure. When you lose blood pressure, your heart rate has to increase to make up for the loss in cardiac output to keep you going. This results in vitals findings that include a low blood pressure and an elevated heart rate. This is part of the discussion around hemodynamic stability, one of my favorite things to talk about.

For example, I’ve had a patient just recently that demonstrated blood pressures at rest 96/54 mmHg and a heart rate of 104 bpm. Sometimes, you don’t see the change in blood pressure and heart rate at rest, but you may see it with activity. The other day, I was teaching an exercise test and our model had resting blood pressure of 120/86 mmHg and a heart rate of 70 bpm. With ONE MINUTE of marching in place, her blood pressure was 130/90 and her heart rate was 50 bpm. She was also having cardiac arrhythmias that were not present at rest. It took ONE MINUTE. That’s it. And, just an FYI, this was NOT a patient. This was your standard run of the mill adult walking around doing their normal thing. This adult could be walking in to your clinic at any moment.


Why, you might ask, are so many of Doctor B’s patients dehydrated? Well, there are lots of reasons. I’m going to use this post to segue into a few other topics, but the gist of it is that they are sick. And when you are as sick as they are, drinking enough water is either difficult or not indicated. That’s right. You read that correctly. For some of my patients, drinking too much water is actually exactly their problem. You can read more about that here. But the REAL REASON that many of my patients are dehydrated is because I check for it. Simply because I check for it, I’ve significantly increased the number of dehydrated adults on my caseload. Just because someone is sick doesn’t mean they are dehydrated, but if you never check, you’ll never know.

Many of my patients have difficulty breathing. Many of them have COPD or some other form of lung disease. If it’s difficult to breathe at rest, getting up to get a drink of water is going to be pretty challenging, so many of them just don’t. For people who use supplemental oxygen, staying hydrated is even more important because their supplemental oxygen is very dry, even when using a humidifier, and causes cracks and bleeding in their nose. This causes discomfort and decreases compliance with their oxygen.

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If you’ve read my posts on heart failure, including the post that covers the Rule of 2s in relationship to heart failure, you can understand how too much water can actually become a problem. For patients who manage chronic heart failure, their fluid restriction (typically of 2 liters of water per day) can make them fairly dry, especially in the beginning of their disease. They are used to drinking as much water as they need, but all of a sudden, we are telling them they have to ration it out over the course of the day. Initially, they have to adjust to this change so they have some time frame of mild orthostasis or other dehydration symptoms. Funnily enough, they usually do fine for a while, but then they get too good at limiting their fluid intake and they start to REALLY limit themselves. Some patients are proud to announce that they can only drink 1 liter of water per day… And Doctor B cringes… Even when they have a fluid restriction, it is still important to drink to the max of their restriction to ensure they stay hydrated enough to function.

Many of my patients are also incontinent. We will talk more about this later, but the solution many of them think they’ve discovered is that, if they drink less water, they won’t have to get up to use the bathroom as often (which is hard for them to do, or requires the assistance of another person and they don’t want to be a bother). Unfortunately, this results in these older, more fragile people becoming dehydrated which produces hypovolemia, which results in increased sodium and potassium concentrations in their body (hypernatremia/hyperkalemia), which results in altered mental status and/or heart problems. Unfortunately for them, drinking less water doesn’t actually reduce their urination frequency….

That’s right, decreased water intake doesn’t really decrease your urine frequency. What actually happens is that your urine becomes more concentrated in your bladder. This concentrated urine becomes a bladder irritant which actually increases the frequency of feeling the need to go! This is especially true of those middle of the night trips to the bathroom that we all know result in falls. People stop drinking water and hour or two before bedtime so they won’t have to get up to use the bathroom in the night. But, darn it, that’s just not how it works. Now they will actually be getting up more often to use the bathroom because they are getting dehydrated before bed.

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Let’s factor in how often urinary incontinence co-occurs with chronic diseases, especially those of the respiratory system. You don’t have to go out and do your own research, I’ll just tell you: It’s pretty much every time. My patients often have to cough to clear secretions, because their throat is too dry, or because they have swallowing impairments. When they cough they become incontinent. They have trouble getting up so they just don’t. Then, they sit in that extra-concentrated urine until they muster the energy or someone is available to help them. They end up developing urinary tract infections which take them down the long spiraling road of confusion, falls, injuries, and hospitalizations.


Setting doesn’t matter. Many of my chronic disease folks are in the home health setting, but I saw plenty of dehydration in outpatient orthopedics, too. Even in the Skilled Nursing Facility where the nurses do daily rounds to check vitals, many more than once per day, I still check every patient before exercising them. Patients in facilities tend to be pretty dry, partially because they can’t get more to drink on their own. Finding patients too orthostatic to participate in therapy and recommending fluids has become a regular intervention.

I think you can all pretty much get the picture as to why not drinking enough water is really bad, especially for the older population or those with chronic diseases. And the threshold is pretty narrow for many people if they also have a fluid restriction. But, do you remember why I said so many of my patients have dehydration? The REAL reason? It’s because I check for it. And so should you.

Vitals. Every patient. Every time. More than once.

And you can be the one to prevent that hospitalization or that infection or that fall. All you have to do is look for it to know it’s there. Then you can intervene and be the hero with just a cup of water.


How many cups of water do you drink every day? Let me know in the comments!

ABGs (Part II)

So, now that you’ve read all the basics about ABGs in the first post, here is a little more about interpreting lab values and how to determine compensated conditions. This is where it gets fun! First off, let’s take a look at what NORMAL lab values probably look like: pH: 7.35-7.45 Partial pressure of oxygenContinue reading “ABGs (Part II)”

COVID Brain

Research is piling in regarding the neurological effects of COVID-19 and the depth of the research is giving us some really concrete information to help guide treatment, screening, and monitoring strategies. The anecdotal evidence is continuing to build quickly so I’ve significantly updated this post to reflect some of the more recent changes and findings.Continue reading “COVID Brain”

According to the Scientific Community, It’s Time for Change

If you couldn’t tell, I’ve been hinting at this for a while. In several posts over the past few months, there has been discussion amongst the medical community that has created controversy regarding the mode of transmission of COVID-19. Many providers of all disciplines have been very concerned about their contraction rates and that ofContinue reading “According to the Scientific Community, It’s Time for Change”

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