Continence and Balance

Question 1

Briefly describe the different types of incontinence.

Answer 1

1. Stress Incontinence:

• Involuntary leakage of urine when bladder pressure exceeds urethra pressure (no detrusor contraction)
• Usually small amount
• Cough, sneeze, laugh, lean over

2. Urge Incontinence

• Loss of urine associated with strong sense of urgency
• Need to void too soon to get to toilet (warning)
• Frequent voiding
• Triggers set off voiding

3. Reflex Incontinence

• Loss of urine due to detrusor hyperreflexia
• Involuntary urethral relaxation

4. Overflow Incontinence
   * Involuntary loss of urine due to overdistention of bladder C/o dribbling Incomplete emptying Blockages
5. Functional Incontinence

• Leakage due to Inability to get to bathroom
• Cognition
• Psychosocial
• Environmental
  
  • Barriers
  • GET them on bladder schedule

Question 2

Identify and briefly describe interventions for incontinence.

Answer 2

Treatment

• Kegel’s exercises
• Pelvic floor exercises
• Estim
• Biofeedback
• Habit training (must make them go every 2 hours or so)
• Prompted voiding
• Crede, ValSalva
• Diet
• Medication
• Catherazation
• Continence pads and briefs
• Surgery
• Suppositories
• Schedule
• Pads and briefs

Question 3

What are risk factors for incontinence?

Answer 3

Pressure system

• As long as pressure in urethra is higher than pressure in bladder, will be continent
• When pressure in bladder is higher than pressure in urethra, will void

Micturation

• Spinal reflex. When bladder distends to certain level will trigger this reflex.
• The way infants void
• Continence is a learned behavior
• Bladder fills to about 250-350 ml urine
• Sends signals to cortex that need to void
• Continue passive filling
• Cortex controls and looks for a bathroom
• In bathroom cortex triggers the voiding response.
• Contract detrusor, abdominal muscles, trigone
• Relax sphincter, bladder neck, urethral muscles, pelvic floor muscles
• When done, go back to rest state
• Cortical control (inhibition) of this reflex
• If cannot get to a bathroom, will eventually not be able to control and will become incontinent.

Question 4

BALANCE

How is balance defined?

Answer 4

• Control body center of gravity (COG) over base of support(BOS)
• COG normally just anterior to spine at S2
• BOS depends on points of support—includes area covered by points of support
• Involves organization of sensory input with planning & execution of motor output
• Inputs: visual, proprioception, vestibular
• Outputs: muscle tone, reflexes, movement
• Impairment due to anything that affects any of the above

Question 5

What is the BOS and the COG, and what is the relationship between the BOS and COG?

Answer 5

BOS

• Parts of the body that experience pressure due to weight & gravity (parts that are “touched down”)
• Can have multiple BOS
• Larger BOS more stable

Shape of BOS

• Shape of BOS also affects stability
• Limit to where can maintain balance (edge of BOS) is called limit of stability
• If COG goes past the limit of stability must either
• Pull COG back over BOS
• Establish a new BOS under the COG
• Fall
• Normal stance, COG is in middle and stable front to back or side to side
• Tandem standing, COG in middle and more stable front to back but less stable side to side

External Environmental Influences

• Support surface
• Gravity
• Wind
• Light
• Head movements needed
• Movement to get around in environment

Question 6

Explain how reflexes and automatic postural responses affect balance.

Answer 6

Dynamic equilibrium

• Interaction between
• Individual
• Task
• Environment
• Uses both feed forward and feed back
• Constant cyclical nature

Reflexes

• VOR—allows visual tracking with either fixed or moving head
• VSR—allows stable body when head moved
• Righting reactions
• Crossed extensor reflex

Automatic Postural Responses

• Goal to keep COG over BOS
• Always occur in response to a stimulus
• Very fast—not under volitional control
• Response matched to stimulus in force & direction
• 4 common strategies in usual order employed
• Ankle
• Hip
• Suspensory
• Stepping
• Anticipatory Postural Response
• Postural set & tone
• Volitional Postural Response
• Volitional set & tone

Question 7

Identify areas for evaluation, assessment, and observation that can be used to measure balance.

Answer 7

Observation of:

• Asymetric postures
• Variances of BOS (sitting and standing)
• Completion of function tasks
• Evidence of “Righting, Equilibrium, Protected Reactions and Balance”
• Evident of “Primitive Reflexes”
• Static and dynamic (sitting and standing)
• Record # of LOB, &assist required to recovery
• Poor to Good Scale
• TUG (timed up and go)
• Physical Performance Test (p 416)
• Berg Balance Score
• Tinnetti Balance Test