Age-Related Changes in Skeletal Muscle - PowerPoint

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I. Definition:
II. Normal urination
IV. Causes of Stress Incontinence.
V. Incontinence and Aging
VI. Evaluation
-     Clinical History
-     Examination
VII. Treatment:
2-Devices :
    - Kegel exercises :
    - Weight Training .
4- Biofeedback.
5- Electrical Stimulation
    Definition: The definition of incontinence is
the passing of urine in an undesirable place.
  Normal Urination
       A normal urination pattern in adults
(1) maintenance of dry underclothes at all times;
(2) urination volume of approximately 300 to
400 ml at each void;
 (3) urination frequency of approximately 4 to 6
times during the day and no more than once at
night; and
(4) urination without any discomfort, excessive
effort, or false starts and stops.
       Several components are needed to maintain
       The continent individual must ;
a) recognize the need to urinate,
b) locate the proper place to urinate,
c) reach that place to urinate in an efficient time period
d) retain the urine until the place is securely reached,
e) be able to urinate once arriving at the proper place.
       In older adults, particularly those who are disabled
or hospitalized, incontinence may result more from the
inability to reach the desired place than from any true
urological impairment.
       Many facilities have like beds or chairs that are
hard get out of and toilets that are difficult to reach, are
factors which exacerbate this problem.
      Women experience incontinence twice as
often as men, with 15% to 30% of women in all age
groups affected.
      Among middle-aged women, research
indicates that 58% reported some urine loss, but
only 25% sought treatment.?
      Among non-institutionalized women older
than 60, it was found that 37.7% suffered from
      Lack of control over urination is one of the
five main reasons for admission to a nursing home,
along with immobility, cognitive impairment, falls,
and the consequences of stroke.
Causes of Urinary
 Incontinence UI
The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus, and
    associated connective tissue which span the area underneath the pelvis.
The levator ani is usually considered in three parts: pubococcygeus, puborectalis, and iliococcygeus
1-Stress incontinence
• Two main causes of stress incontinence exist.
• The major cause is impaired urethral support
  from pelvic floor muscle weakness.
• The less common cause is an intrinsic sphincter
  deficiency usually from pelvic surgeries.
• In either case, diminished urethral sphincter
  function diminishes and its function is
  compromised with increased abdominal pressure.
• Stress incontinence is characterized by urine
  leakage associated with increased abdominal
  pressure from laughing, sneezing, coughing,
  climbing stairs, or other physical exertion.
• 2- Urge incontinence or Hypertonic
• Urge incontinence is a result of uninhibited bladder
  contraction from detrusor hyperactivity.
• This hyperactivity can be caused by abnormalities of
  the CNS inhibitory pathway such as strokes and
  cervical stenosis. Other causes are bladder
  inflammation from infection, stones.
• Urge incontinence is characterized by involuntary
  urine loss accompanied by a sudden strong desire to
  pass urine that is difficult to suppress.
• Some individuals may have a pure sensory abnormality
  where they exhibit urinary frequency and urgency
  without urine loss. This is often referred to as
  overactive bladder dry.
• Elderly persons frequently experience urinary loss
  without the sensation of urge, but the underlying
  mechanism of detrusor hyperactivity is still the same.
3-Mixed incontinence
• Mixed incontinence is the coexistence of stress
  and urge incontinence.
• Mixed urinary incontinence is characterized by
  involuntary loss of urine associated with
  urgency as well as exertion, cough, sneeze, or
  any effort that increase intra-abdominal
• Mixed incontinence is the most common type
  of incontinence in women.
4-Overflow incontinence or Hypotonic
• Overflow incontinence is incomplete bladder
  emptying secondary to impaired detrusor
  contractility or bladder outlet obstruction.
• Factors involved in the development of overflow
  incontinence are physical obstruction, such as
  pelvic organ prolapse and enlarged prostate
  and neurological abnormalities, such as spinal
  cord injuries. It is also commonly associated
  with bladder neuropathy as occurs in diabetes
• Patients often complain of continuous small-
  volume leakage associated with weak urinary
  stream, dribbling, hesitancy, frequency, and
5- Functional incontinence
Functional incontinence occurs when a person does not
   recognize the need to go to the toilet, recognize where
   the toilet is, or get to the toilet in time.
The urine loss may be large. Causes of functional
   incontinence include confusion, dementia, poor
   eyesight, poor mobility, poor dexterity, or unwillingness
   to toilet because of depression, anxiety or anger.
People with functional incontinence may have problems
   thinking, moving, or communicating that prevent them
   from reaching a toilet.
A person with Alzheimer's Disease, for example, may not
   think well enough to plan a timely trip to a restroom.
A person in a wheelchair may be blocked from getting to
   a toilet in time. Conditions such as these are often
   associated with age and account for some of the
   incontinence of elderly women and men in nursing
6- Other less frequent causes
• Include trauma from pelvic fracture,
  complications of urologic procedures, and
• "Transient incontinence" is a temporary version of
  incontinence. It can be triggered by medications,
  urinary tract infections, mental impairment,
  restricted mobility, and stool impaction (severe
  constipation), which can push against the urinary
  tract and obstruct outflow.
• Incontinence can often occur while trying to
  concentrate on a task and avoiding using the
       Incontinence and Aging
      The older old (older than 75 years) are more
likely as a group to suffer from incontinence.
      1-Aging in general has an impact on UI
partially because of obstruction of the bladder
outlet (urethra) in older adults, which is probably
due to diminished or absent urethral compliance or
lack of detrusor contractility.
      2- Older people may be more susceptible
urinary incontinence due to side effects of
pharmaceuticals, lack of necessary social and or
medical support, or an interaction of various
pathologies that can lead to functional disability.
   3- As the urinary system ages, the kidneys have
diminished urine concentration, which leads to
increased volume of urine passing through the
   4- In conjunction with other effects of aging such
as hypotrophic changes in collagen, elastic tissue,
and smooth muscle of the bladder, this change in
urine volume results in more frequent micturition.
   5- Decreased muscle tone in bladder, internal
and external sphincters, bladder outlet, and pelvic
muscles also contributes to an elderly women's
tendency toward UI.
   6- Other age-related changes in women are
reduced urethral closure pressure that is possibly
due to lower estrogen levels, which leads to
decreased submucosal blood supply and decreased
            Clinical History:
       All patients (especially those >65 y)
should be asked specific questions about voiding
- Onset (pregnancy, postpartum, surgery, trauma)
- Duration of complaint
- Patterns (nocturnal vs diurnal)
- Precipitants (cough, sneeze, and position
change, sound of running water).
- Frequency/severity/quantity
- Voiding diary.
        Proper examination of the pelvic floor muscles lays the
foundation for a plan of intervention.
1- One of the most commonly used methods for evaluation of
pelvic floor action is the modified Oxford scale, which uses a
number to represent a certain grade of muscle power.
        The scale measures contractions from a low of 0 for no
contraction (nil) to a high of 5 for a strong contraction.
        Intermediate scores of 1, 2, 3, and 4 correspond to
muscle ratings of flicker, weak, moderate, and good.
        This scoring system can be adapted to measure muscle
endurance by determining the duration and repetition of quick
 2- Visual inspection of proper contracting and lifting activity
of the pelvic floor also can be used to assess impairment.
  3- Self-assessment can be performed by the stop test. A
stop test simply tests the ability to stop the flow of urine.
       It is recommended as an occasional-use test only.
Performing this measure of urine control on a regular basis
is contraindicated because it may trigger bladder instability
or infection.
 4- Urodynamic testing and other examination procedures
to assess the extent of leakage in response to increased
abdominal pressure, such as the pad test, may be performed
by the therapist or other health care professionals.
       During a pad test the subject is asked to wear a pre-
weighed pad and to drink 500 ml of fluid in a set period of
time, such as 15 minutes.
       Next, the subject performs a variety of set functions
for 30 minutes, including sit to stand, walking, jumping,
reaching for an object on the floor, and running water over
the hands. The pad is then re-weighed to collect data on
urine loss during activity.
I. Advices:
      There are several things patients can do to
help improve continence.
1-Avoid       overconsumption        of     diuretics,
antidepressants, antihistamines, and cough-cold
2- Perform Kegel exercises daily.
3- Practice double voiding (urinate, wait a few
seconds, urinate again).
4- Eat fruits, vegetables, and whole grains daily to
prevent constipation.
5- Retrain the bladder (urinate only every 3 to 6
6- Stop smoking (nicotine irritates the bladder).
II. Devices :
      A number of protective devices are available
to help manage accidental urination, including the
1-Bed pads
2- Combination pad-pant systems
3- Disposable or reusable adult diapers
4-Full-length absorbent undergarments
5-Male incontinence drip collectors
6-Underwear liners (pads, guards, shields, inserts)
      Early reliance on absorbent pads may cause
the wearer to accept incontinence rather than seek
diagnosis and treatment.
      These products should be applied correctly
and changed often to prevent skin irritation and
urinary tract infection
III. Exercises
1- Kegel exercises :
        The muscle group strengthened through Kegel exercises is
the pubococcygeous muscle group.
        These muscles relax under your command, to control the
opening and closing of your urethral sphincter: in other words,
they are the muscles that give you urinary control.
        When they are weak, leakage occurs. Through regular
exercise, however, you can build up their strength and endurance
and, in many cases, regain control.
        When instructing a patient on how to contract the pelvic
muscles, the therapist should first have him/her assume a
comfortable supine position with the legs well-supported and
       The first step is to properly identify the muscle
group to be exercised.
- The patient should be instructed to tighten or draw up
the muscles around the openings of the vagina, urethra,
and rectum as if he/she were trying to prevent the flow of
urine ( lift and squiz).
-As you begin urinating, try to stop the flow of urine
without tensing the muscles of your legs.
- It is very important not to use these other muscles,
because only the pelvic floor muscles help with bladder
-When you are able to slow or stop the stream of urine
you have located the correct muscles.
-Feel the sensation of the muscles pulling inward and
-The therapist then encourages the patient to notice
the muscle tension and hold the contraction as long
as possible (striving for a goal of a lO-second
- The patient should then allow the muscle to relax
or rest for twice as long as it contracted, i.e., if
contraction is held for 3 seconds, the patient should
rest for at least 6 seconds.
-The therapist should then have the patient repeat
the cycle of contraction and relaxation and increase
his/her awareness of the muscle action.
- At this point the patient should be able to feel the
pelvic muscles working.
- The baseline muscle performance should be
measured by recording how long a contraction can
be held and how many times it is repeated.
       After noting this baseline assessment of
performance, the patient should be encouraged to increase
the repetitions, duration, and frequency of the exercises.
       Various recommendations range from a high of 300
to 400 repetitions per day to as few as three to four
maximal contractions performed three times a week.
       Other exercise regimens can be performed in a
group exercise setting using several positions with the
legs abducted, in which 8 to 12 contractions are
performed by the patient in each position followed by
       This exercise prescription is recommended for use
as a home program of 8 to 12 repetitions in a set
performed 3 times per day.
2-Weight Training
         Resistive exercise for the pelvic muscles can be perfonned
using weighted vaginal cones.
         Cones are usually packaged in sets of five that gradually
increase in weight, ranging from 20 to 70 grams.
         For this exercise, the patient simply places the small plastic
cone within her vagina, where it is held in by a mild reflex contraction
of the pelvic floor muscles.
         Because it is a reflex contraction, little effort is required on the
part of the patient.
         A woman inserts the heaviest cone that can be retained for at
least 1 minute and then progresses to heavier cones and increased
duration and difficulty of retention during activity as her strength
         One treatment regimen recommends that the patient insert a
cone twice a day and walk around for 15 minutes.
         If the cone slips, the patient should reinsert the cone. When the
cone can be retained, the cone with the next highest weight can be used,
or the patient can try to use the same cone with more challenging
activities, such as jumping.
         Visual and auditory feedback can be provided using a
perineometer or electronic biofeedback (BF) modalities.
         The perineometer transmits pressure changes relating to pelvic
muscle contractile forces.
         Electronic devices during examination can pick up a very
sensitive range of signal from the musculature using external or internal
         The success rate of visual and/or auditory feedback in muscle
re-education resulting in diminished episodes of urine leakage has been
estimated as ranging from 54% to 90%.8
         There are four conditions contribute the successful use of this
- an easily measurable and detectable response;
- an ability to detect change in that response;
- a cue to control need;
- and motivation of the patient to be actively involved in the treatment
4-Electricnl Stimulation
         Electrical stimulation uses faradic or interferential current
delivered via internal or external electrodes to recruit muscles fibers,
beginning with large-diameter fibers and eventually engaging the
small-diameter fibers.
         Electrical stimulation can be used to achieve the following
anticipated goals:
1-enhance storage of urine by altering bladder sensation via afferent
fiber stimulation,
2- stimulate detrusor muscle activity to contract the bladder via efferent
3- improve circulation to the muscles and capillary nerwork,
4- and promote muscle hypertrophy.
         Treatment protocols vary, and intensity is determined according
to patient tolerance.
         A stimulation frequency of 35 Hz provides muscle feedback
and can elicit a cortical response.
         A frequency that is too high may unduly fatigue a muscle.
Pulse width is generally set at 200 to 400 microseconds with adequate
rest period, usual at least equal to or longer than the stimulation phase.

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