Pelvic Floor Physiotherapy for Patients with Neurologic Dysfunction

Beth Safarian, MScPT, PT

Pelvic floor therapy can be a very valuable service for patients who have neurologic dysfunction. We treat patients who have multiple sclerosis, Parkinson’s disease, amyotrophic lateral sclerosis, spinal cord injury and stroke. Historically, bladder, bowel and sexual symptoms for this population have just be accepted as an untreatable side effect of their condition. However, there are many behavioural strategies and pelvic floor exercises that make an impact for this population.

What to expect at your initial pelvic physiotherapy session?

In order to get an understanding of a clients bladder or bowel symptoms, your physiotherapist will likely send you home with a bladder and/or bowel diary at your first appointment. A bladder diary will require you to measure your voids (either by counting how long the stream is or by urinating into a measurement container), record your fluid intake and make down any incidents of urinary incontinence. Similarly, a bowel diary will require you to record the time, consistency and volume of your bowel movements. They may also include keeping track of how much fibre you get in a typical week. These diaries allow your physiotherapist to analyze your habits and symptoms so that they can give you the most helpful recommendations.

Common Symptoms with Neurologic Dysfunction

One of the most common symptoms we see with neurologic dysfunction is bladder retention. This is a condition in which the bladder is unable to adequately empty the urine out. In these situations, it is important to incorporate techniques which promote pelvic floor relaxation. When these muscles relax fully, it triggers the bladder muscle (called the detrusor) to contract which results in the bladder emptying urine. We will focus on behavioural modifications such as toilet positioning, double voiding and relaxation techniques to promote as much emptying as possible. Additional techniques include using warm water, a vibrator and/or gentle pressure externally on the bladder to trigger the bladder to empty further. Some clients may deal with more severe retention which requires them to self-catheterize. These clients are at an increased risk of urinary tract infections so your therapist will educate you on strategies to prevent and reduce these infections.

Similarly to bladder retention, constipation is very commonly seen in this population. After assessing their bowel diary, the first step is always to address diet. If a client is struggling to get sufficient fibre in their diet, they may benefit from a psyllium supplement. Adequate water intake is also extremely vital to preventing the stool from becoming too firm. We do a lot of education on the importance of a consistent bowel routine which often includes getting up at the same time most mornings, having a small breakfast within 30 minutes of waking, and including a warm drink with their breakfast. The bowels respond well to routine and regularity so staying consistent can be quite helpful. Part of the reason constipation is so common in this population is because of a decrease in peristalsis of the colon, which means the smooth muscle in the colon isn’t contracting as well to move waste through the system. Your physiotherapist may teach you how to do an abdominal massage on yourself at home to stimulate more movement in the digestive tract. Similiarly, you may be advised to use interferential current on the abdomen as an at-home treatment to improve motility.

Other Treatment Options

If a client’s pelvic floor has low muscle tone, weakness, decreased coordination and/or reduced proprioception, your therapist may suggest electrical muscle stimulation. This involves using electrodes externally or a probe internally. An electrical stimulation is sent from the machine which is attached to the probes to stimulate the muscles and nerves of the pelvic floor in order create a pelvic floor muscle contraction. As an alternative to electrical muscle stimulation, your therapist may suggest trying biofeedback. This also involves electrodes and/ or probes, but it does not contract the pelvic floor. The purpose is for the client to see on the screen when their pelvic floor is contracting versus relaxing. This option may be better for those with decreased sensation.

While there are unique treatment approaches to those who have neurogenic bladder or bowel, your therapist will also likely use your more typical techniques like breathing, lumbo-pelvic mobility and pelvic floor strengthening exercises. The goal is still the same as treating patients who do not have neurological dysfunction - optimizing strength, coordination and awareness of the pelvic floor muscles. Although a pelvic health therapist cannot change nervous system pathologies, we can help find treatment techniques and strategies that manage your symptoms and help you improve your quality of life.