Geriatric Physical Therapy 3rd edition

TA B L E 1 8 - 1 Functional Balance Measures—cont’d Balance Type of Balance Items Included Equipmen Measure Assessed (Sitting, Required Standing, Dynamic Standing, Gait) Four canes stopwa The four-square step Examines dynamic standing Stepping over canes test (FSST)95 balance through measuring forward, backward, and the ability to perform mul- sideways tidirectional movements The Berg Balance Examines standing and 14 total items: sitting to Chair, stoo Scale (BBS)96 dynamic standing standing, standing yardsti unsupported, sitting with stopwa back unsupported but feet supported on floor or on a stool, standing to sitting, transfers, stand- ing unsupported with eyes closed, standing unsupported with feet together, reaching for- ward with outstretched arm while standing, pick up object from the floor from a standing position, turning to look behind over left and right shoul- ders while standing, turn 360 degrees, place alter- nate foot on step or stool while standing unsup- ported, standing unsup- ported one foot in front, standing on one leg

nt Interpretation Administration The Main Uses of the 344 CHAPTER 18  Balance and Falls s and a of Scores Easy to administer, Measure in Older atch takes approximately Adult Population The cutoff score is 5 minutes or less to ol, .15 seconds.95 Sensi- complete Used as a screening tool ick, tivity score of 89%, and for older persons.95 It atch for nonmultiple fallers a A skilled evaluator can can assist with helping specificity of 85% with complete the test in the clinician to deter- a positive prediction less than 15-20 mine if the patient can value of 86%95 minutes change directions quickly. Backward Score , 45: high risk for stepping is particularly falls97 difficult Scores # 36: 100% chance Used for patients who of falling in the next 6 exhibit a decline in months in older adults98 function, self-report a loss of balance, or However, it has been sug- have unexplained falls gested that the BBS is best used as a score Can predict fall risk of with no cutoff value as- older adults. Good to cribed to fall risk, as fall use for persons of risk increases signifi- lower functional ability cantly as the score on also because the tests the test decreases99 incorporate sitting and standing but no loco- motion. A person can- not use an assistive device

The Physical Examines dynamic Nine total items: sentence Pencil and Performance Test balance such as turning writing, simulated eating, a jacke (PPT)100 360 degrees and picking turning 360°, putting on book, a up a penny from the floor and removing a jacket, stopwa lifting and then placing a and sta The Short Physical Examines standing, dynamic book on a shelf, picking Performance standing, and gait up a penny from the Chair and Battery (SPPB)102 floor, a 50-foot walk test, watch and two measures of Dynamic Gait Index Examines gait stair climbing (time to Boxes, con (DGI)67 ascend one flight; steps number of flights climbed Timed Up and Go Examines gait up and down) 100 Chair with (TUG)68 rests a Three types of physical ma- stopwa neuvers: the balance tests (Romberg, semi- tandem Romberg, tan- dem Romberg), the gait speed test, and the chair stand test102 Eight total items: gait level surface, change in gait speed, gait with horizon- tal head turns, gait with vertical turns, gait and pivot turn, step over ob- stacles, step around ob- stacles, and steps The therapist measures the time an older adult needs to stand from a chair with armrests, walk for 3 m, turn around, and return back to the chair and sit down at his or her normal, comfort- able speed Gait speed104 Examines gait Timed walking over 3-4 m Stopwatch

d paper, Detect risk of falling Easy to perform within Used as a follow-up tool  CHAPTER 18  Balance and Falls 345 et, a 10 minutes to monitor changes in a penny, physical frailty, quality atch, of life, and increasing airs function following ex- ercise training pro- grams including strength training and treadmill walking101 stop- Scores #10: high risk of Easy to administer and Used as a predictive mea- mobility disability102 safe, takes sure for morbidity and 10-15 minuets mortality in older per- sons102 nes, and A score #19 was found to It takes 10 minutes or Used to assess older be predictive of falls in less to administer adults’ ability to mod- h arm- older adults 98 ify gait and maintain and normal pattern and Older adults who took Very easy to administer pace in response to atch 13.5 seconds were Easy to administer changing task classified as fallers, with demands67 h an overall correct prediction rate of 90%.103 Used to measure the func- tional mobility in older A score 30 seconds indi- adults that is impor- cates that the patient tant for ADL will have significant difficulties in ADL.103 Used as a measure of functional exercise ca- It is a very reliable test with pacity in older adults high sensitivity (87%) and specificity (87%).103 Predict hospitalization and mortality rate105; 0.1 m/second change is considered clinically significant104

346 CHAPTER 18  Balance and Falls 4, each grade with well-established criteria. Zero indi- cates the lowest level of function and 4 the highest level measured via a yardstick affixed to the wall. It is a useful of function. The total score ranges from 0 to 56. measure for patients complaining of falling. A reach The BBS is reliable (both inter- and intratester) and has of less than 6 in. has been reported as a risk factor for concurrent and construct validity.107,108 falling within the next 6 months, with an adjusted odds ratio of 4.0.93 Although a cutoff score of greater than 45 has been traditionally identified as a useful cutoff to predict falls The multi-directional reach test (MDRT) was devel- in those who scored below the cutoff score,97 recent oped by Newton94 to determine how well older adults work by Muir and Berg99 suggests an alternative scoring could reach forward, to the side, and backward. A yard- system as well as suggesting that the BBS is more effec- stick fixed to a telescoping tripod at the level of tive in identifying those who will fall more than once the acromion was used. Their instructions included than those who have fallen one time only. They suggest “without moving your feet or taking a step, reach as far a cutoff score of 40 to predict those who will experience as you can to the (right, left, forward, or lean back- multiple falls (positive likelihood ratio of 5.19 with 95% wards).”94 The test appears to be a reliable and valid confidence interval [CI] of 2.29 to 11.75) and injurious measure of the “limits of stability.”94 Forward reach is falls (positive likelihood ratio of 3.3 with 95% CI of less when done via Newton’s test compared to the func- 1.40 to 7.76). In the Shumway-Cook et al model for us- tional reach test. This difference is most likely because ing the BBS to predict the likelihood of falling, a score of the tripod is not located next to a wall. Fear of falling 36 or less indicated a nearly 100% chance of falling in may prevent people from reaching further.94 the next 6 months in older adults.98 The BBS is less use- ful in confirming someone is at low risk of falling. Even Reaching tests can serve as a quick and low-effort subjects who achieve a very high score (53 or 54 of 56) mechanism for gathering crucial information regarding only have a moderate assurance that they are not at the postural stability of older adults. Reaching tests risk for a fall in the next few months. The BBS is provide an option for examining postural stability in particularly helpful in determining sitting and standing frail older adults who cannot perform other tests that balance. No measures of gait are directly recorded include ambulation and can be used as a quick screen for within the scale. community testing of seniors. Physical Performance Test.  ​The physical performance Four-Square Step Test.  T​ he four-square step test test (PPT) was developed to assess function in commu- (FSST) has also been used in older adults to assess fall nity-dwelling older adults100 and is a useful measure of risk. The FSST involves stepping over four standard early physical decline in older persons.109 The PPT’s canes at 90 degree angles to each other, whereby the tips relationship with recurrent reported falls demonstrated a all touch each other at the center to create the “four sensitivity of 79% and a specificity of 71% in older squares.”95 The patient is asked to stand in one square men.110 The PPT tool assesses multiple domains while facing forward and then is asked to step clockwise over observing the patient performing various tasks. The PPT the canes by moving forward, to the right, backward, to includes nine items such as eating, putting on a sweater, the left, and then reversing the path in a counterclock- writing, picking up a penny from the floor, turning while wise direction. Both feet are to enter each designated standing, walking, and stair climbing, with three degrees spot. The patient is instructed to move as quickly as pos- of difficulty. An ordinal scale is used based on the time sible without touching the canes with both feet touching that it takes the subject to complete the tasks, except for the floor in each square. They are also asked to face the last item, stair climbing, which is based on the num- forward throughout the testing.95 Interrater reliability ber of flights that the person can ascend and descend.100 has been reported to be r 5 0.99.95 Using a cutoff score of .15 seconds to predict individuals with two or more The Short Physical Performance Battery (SPPB) was falls, the test has good sensitivity and specificity (89% developed to assess risk of falling in older adults.102 The and 85%, respectively).95 The FSST is especially helpful SPPB has three components: (1) the Romberg, semitan- in quantifying how well your patient can change direc- dem Romberg, and tandem Romberg; (2) repeated sit tions and move backward quickly. to stand; and (3) gait speed. Scores range from 0 to 12, Berg Balance Test.  T​ he Berg Balance Scale (BBS) was which has been norm-based on more than 10,000 older developed by Katherine Berg in 1989 to measure balance adults (higher scores indicate better function).111 ability (static and dynamic) among older adults.96 The Dynamic Gait Index.  ​The Dynamic Gait Index (DGI) is BBS is a qualitative measure that assesses balance via particularly useful for individuals with suspected vestib- performing functional activities such as reaching, bend- ular disorders because the test incorporates various head ing, transferring, and standing that incorporates most rotation actions that challenge vestibular responses to components of postural control: sitting and transferring gait activities.112 The DGI is an eight-item test with each safely between chairs; standing with feet apart, feet item graded (0 to 3) as severely impaired, moderately together, in single-leg stance, and feet in the tandem impaired, mildly impaired, or normal, for a maximal Romberg position with eyes open or closed; reaching score of 24.67 Scores on the DGI provide only a modest and stooping down to pick something off the floor. Each item is scored along a 5-point scale, ranging from 0 to

CHAPTER 18  Balance and Falls 347 contribution to falls risk prediction, with both sensitivity need to watch the patient’s performance during routine and specificity generally ranging between 55% and 65% activities within his or her home. The therapist may ob- when the “best” cutoff score of 19 or less is defined as a serve the patient getting in and out of bed and in and out “positive” risk factor.98 However, the ability to observe of the shower or bath tub. In addition, it is important to the interaction of visual and vestibular input when head assess the patient’s access to light switches. Obstacles, movement is superimposed on forward walking may cords, and clutter become particularly relevant to the provide insights into specific impairments that can help patient with serious visual deficits or gait abnormality direct decision making about interventions. Obviously, but need to be addressed only to the extent that they people must be able to ambulate with or without an pose a threat to the patient’s safe function. Environmen- assistive device and need to have the endurance to tal evaluation allows the physical therapist to determine complete the eight gait tasks. the degree of environmental hazard and suggest modifi- Timed Up and Go.  T​ he TUG (described in Chapter 17) cations that aid in preventing falls.116,117 Chapter 7 pro- is a gait-based functional mobility test that is easy to vides further details about environmental assessment. administer, reliable, and has high sensitivity (87%) and specificity (87%) for predicting falls.103 Individuals Psychosocial Assessment taking 13.5 seconds or longer to perform the TUG were classified as fallers with an overall correct prediction rate Social support and behavioral/cognitive function should of 90%. The TUG is advantageous because it includes be addressed in the comprehensive evaluation of patients people who use an assistive device, is not overly time experiencing recurrent falls. Impaired cognition has a burdensome, only requires that individuals be able strong relationship with falls118-127 as it is often difficult to walk 6 m (20 feet) to be included, and provides for the cognitively impaired person to recognize “risky” opportunities to assess more complex balance activities situations and make prudent choices that would prevent such as moving sit to stand and turning around at the a fall. Strong social support can help minimize fall risk halfway point of the walk to return to the chair. by providing a safe and supportive environment that Gait.  G​ ait speed is an essential component to include in allows the cognitively impaired person to function the test battery for older adults with a history of falls. A maximally within their environment. Memory deficits, change of 0.1 m/sec is considered clinically significant in dementia, and depression are health conditions seen older adults. During assessment of gait, the physical thera- with greater prevalence in older adults and that have pist should vary the conditions under which the patient been associated with increased fall risk.128 performs the task.113 For example, it is useful to see how the patient responds to changes in gait speed and direction, Fear of Falling negotiates obstacles, manages with various competing at- tentional tasks,114 and handles changing surfaces and other Fear of falling is a potential behavioral outcome of previ- environmental distractions and conditions. ous falls that may limit older adult activities. One third of older adults who experience a fall develop a fear of Environmental Assessment falling.129 Fear of falling may lead to more sedentary lifestyle with subsequent deconditioning that creates an Environmental factors can either facilitate or hinder ongoing downward spiral leading to frailty130 and the abilities to function within one’s surroundings. The increased risk of future falls.131 Fear of falling has been International Classification of Functioning, Disability associated with the use of a walking device, balance and Health (ICF) recognizes the role of the environment, impairment, depression, trait anxiety, female gender, and providing it a prominent role in the ICF model of a previous history of a fall or falls.132,133 disability.115 The level of disability experienced by an individual depends not only on body functions and The Falls Efficacy Scale International (FES-I) is a structures but also on the environmental support and short tool that records fear of falling and is growing personal factors. in acceptance in Europe, with a recently developed short version. The FES-I consists of either seven134 Patients or their family members may complete a or sixteen135 items that are very similar to the home safety checklist that assesses the home environ- 16-item Activities-specific Balance Confidence Scale ment and highlights extrinsic factors that serve as fall (ABC).131,135 Box 18-4 displays the short-form FES-I. hazards. These data are then incorporated into patient The additional factors on the 16-item version include education interventions. An “in-home” safety check cleaning the house, preparing simple meals, going should be a routine part of the home-care physical shopping, walking outside, answering the telephone, therapist’s role and is occasionally incorporated into walking on a slippery surface, visiting a friend discharge activities of a rehabilitation patient. A safety or relative, walking in crowds, and walking on an check examines things like lighting in the house, types of uneven surface. flooring, availability of grab bars in the tub or shower, and handrails for stairways. The physical therapist may The ABC was developed for use with older adults to attempt to quantify fear of falling.136 The test items,

348 CHAPTER 18  Balance and Falls BO X 1 8 - 4 The Short-Form Fall Efficacy Scale–International (FES-I): Patient Directions, Seven Items That Make Up the Scale, and Response Options Introduction Now we would like to ask some questions about how concerned you are about the possibility of falling. Please reply thinking about how you usually do the activity. If you currently do not do the activity, please answer to show whether you think you would be concerned about falling IF you did the activity. For each of the following activities, please put the number in the box which is closest to your own opinion to show how concerned you are that you might fall if you did this activity. h 1. Getting dressed or undressed h 2. Taking a bath or shower h 3. Getting in or out of a chair h 4. Going up or down stairs h 5. Reaching for something above your head or on the ground h 6. Walking up or down a slope h 7. Going out to a social event (e.g., religious service, family gathering, or club meeting) Answer options: 1 Not at all concerned 2 Somewhat concerned 3 Fairly concerned 4 Very concerned Handling Short FES-I sum scores: To obtain a total score for the Short FES-I, simply add the scores on all the items together, to give a total that will range from 7 (no concern of falling) to 28 (severe concern about falling). Handling Short FES-I missing data: If data are missing on more than one item then that questionnaire cannot be used. If data are missing on no more than one of the seven items, then calculate the sum score of the six items that have been completed (i.e., add together the response to each item on the scale), divide by six, and multiply by seven. The new sum score should be rounded up to the nearest whole number to give the score for an individual. (From Kempen GI, Yardley L, van Haastregt JC, et al: The Short FES-I: a shortened version of the Falls Efficacy Scale-International to assess fear of falling. Age Ageing 37:45-50, 2008.) with varying degrees of difficulty, were generated by Classification of Functioning, Disability and Health empha- clinicians and older adults. Each item is rated from 0% sizes the term participation and defines it as “involvement in to 100% related to how confident the person is that he a life situation.”142 Assessing participation in older adults or she can perform the activity. Lower scores indicate provides information about the level of concern an older greater fear of falling and higher scores greater confi- adult has about his or her specific functional activities, re- dence (less fear) of falling. ABC scores can help catego- gardless of actual observable impairment.143 Activities and rize the functional level across a wide range of capa- participation can be assessed by asking about difficulties in bilities: Scores less than 50 indicate low physical performing daily living activities (eating, dressing, bathing, functioning; scores above 50 and below 80 indicate reading, and sleeping) and outdoor activities (driving and moderate levels of physical functioning; and scores working). In addition, the difficulty in performing recre- above 80 indicate high-functioning older adults.137 ation and leisure activities and relationship with family Lajoie et al138 determined that scores on the ABC and members should also be addressed. the BBS were highly correlated, suggesting that fear of falling is related to falls in older persons. The life habits (LIFE-H) questionnaire can be used to assess participation.144 The LIFE-H was developed to as- The Falls Efficacy Scale (FES) is a ten-item test rated sess the handicapping situations in people with disability on a 10-point scale from not confident at all to com- based on the International Classification of Impairment, pletely confident.139 It is correlated with difficulty getting Disability and Handicap (ICIDH). The intrarater reliabil- up from a fall and level of anxiety. The test–retest ity of using the LIFE-H in the older adult population with reliability was 0.71.139 The FES and fear of falling were disabilities was greater than 0.75 for seven of the ten life correlated.140 habits studied, and overall the interrater reliability (ICC) was 0.89 or higher.145 Participation INTERVENTION The evaluation of participation in older adults at the societal level is another essential area to address. More than 50% of Comprehensive, and frequently multidisciplinary, exami- older adults (50 years and more) reported participation nation and evaluation should guide the management of restriction in a population survey.141 The International the older adult with substantial postural instability.146,147

CHAPTER 18  Balance and Falls 349 The main goal of management is to maximize indepen- addressed and prevented first. Several preventive strate- dence in mobility and function and prevent further falls. gies have been used to reduce the rate of falling by Physical therapists are the health professionals most eliminating factors contributing to falls and improving uniquely prepared to analyze movement dysfunctions balance and gait. Table 18-2 provides a listing of the and provide interventions to address the physical func- common fall risk factors and strategies used by physical tional impairments and limitations contributing to the therapists to decrease or eliminate these risk factors. movement dysfunctions. Overall prevention and intervention management can be categorized into medical, rehabilitative, or environmen- The physical therapist may be working in an environ- tal strategies. ment that allows them to be part of an existing interdis- ciplinary geriatric assessment or management team or Medical strategies include careful review and modifi- may refer to and collaborate with other health profes- cation of medications used by older adults.2,146 Four or sionals to achieve a team approach as needed. Other more medications, or any psychotropic medications team members may include a physician, social worker, (neuroleptics, benzodiazepines, antidepressants), should nutritionist, occupational therapist, nurse, and psycholo- be reviewed to see if all are needed.146,148 In addition, gist or counselor. Existing fall risk factors should be any combination or interaction between drugs should be TA B L E 1 8 - 2 Fall Risk Factors, and Strategies a Physical Therapist Should Consider to Ameliorate the Risk Factor and Improve Patient Function Fall Risk Factor Strategies to Ameliorate the Fall Risk Factor Weakness • Individualized muscle strengthening program followed by Loss of flexibility and range of motion • Community exercise program for continued participation in strength training Low/high body mass index • Stretching program Impaired vision • Modifications if range of motion cannot be achieved • Refer patient for consultation with a physician Impaired recreation • Refer patient for consultation with a nutritionist • Assess for depression Impaired sensation • Determine when the patient received their most recent glasses • Refer patient for consultation with an ophthalmologist if any undiagnosed or changing Cognitive impairment visual impairments • Patient education on environmental strategies to minimize risk in the presence of im- paired vision • (Be sure physical therapist’s environment adequately accommodates low vision needs.) • Careful listening to the patient’s interests and desires for specific recreational activities, and strategize options to achieve participation (in typical or adaptive form) • Building a rehabilitative program to address the specific skills required to participate in the activities • Recommendations for local programs that provide recreational opportunities consistent with the individual’s capabilities. • Exercises to maintain or improve distal muscle strength • Tai Chi has been demonstrated to be successful at enhancing distal sensation • Patient education in skin checks to prevent injury to feet: • Daily check of skin on feet • Wearing cotton socks • Checking shoe wear and condition frequently • Patient education in use of alternative balance systems (visual and vestibular) to maxi- mize balance function. • Future direction could be subthreshold vibration in the shoe • Review of medication, with particular emphasis on medications with a sedative effect • Attempt to keep the environment consistent • Evaluate the environment for safety hazards • Family education on safety and monitoring in the home setting • Participation in exercise and physical activity programs appropriate to individuals with cognitive impairment • Referral to primary physician if cognitive impairment is new or has demonstrated substantial change recently Continued

350 CHAPTER 18  Balance and Falls TA B L E 1 8 - 2 Fall Risk Factors, and Strategies a Physical Therapist Should Consider to Ameliorate the Risk Factor and Improve Patient Function—cont’d Fall Risk Factor Strategies to Ameliorate the Fall Risk Factor Incontinence • Patient and caretaker education in establishing a regular toileting program Environmental hazards • Patient and caretaker education about effects of caffeine and particular risks of exces- Postural hypotension sive fluids late in the day requiring trips to the bathroom at night • Consultation with physician, as indicated, for medication management Osteoporosis • Provide an environmental assessment: Polypharmacy Impaired gait • Stability of furniture likely to be used to assist with ambulation in the home Impaired balance • Need for grab bar, tub floor mat installation in the bathroom Joint pain • Recommend handrails on steps • Adequacy of lighting and accessibility of light switches • Assess clothing and footwear • Consult with the physician about a medication review or need for a cardiovascular referral • Patient assessment for, and education in, physiological maneuvers beneficial in decreas- ing an orthostatic event: • Active movements of the lower extremities prior to moving from sit to stand • Use of elastic pressure stockings or an abdominal binder • Slowly move from supine to sit • Ankle pumps or upper extremity movement prior to changing position • Standing exercises/weight-bearing exercise • Consider hip pads • Patient education in the benefits of medications and vitamin D supplementation • Review of medications: Consult with physician if signs that an adverse medication re- sponse may be affecting balance, particularly those causing postural hypotension or confusion • Attempt, with the help of the team, to determine if benzodiazepines are necessary • Determine factors contributing to the gait disturbance • Balance exercises • Establish a walking program • Assistive device use or modification • Exercises performed in standing • Attempts to increase the person’s limits of stability in all directions • Strengthening program • Physical agents as an adjunct monitored carefully, especially drugs that contribute to deficits, with recommendations to the patient for obtain- fall risk, such as sedatives and hypnotics.146,147 ing an eye examination. Another medical strategy is to address visual problems The use of vitamin D plus calcium in persons in long- that might be corrected simply by changing eyewear. term-care facilities has been found to decrease the num- Glasses with prisms can compensate for peripheral-field ber of falls over the intervention period.149,150 Vitamin D deficits, tinted glasses can increase contrast sensitivity, and calcium together reduced the risk of falling by 49% and different glasses for near and far vision can reduce compared to calcium alone.150 There were associated problems caused by bifocals. Lord et al suggest that mul- improvements in musculoskeletal function by vitamin tifocal lenses impair both edge-contrast sensitivity and D and calcium intake. Vitamin D may be more useful in depth perception.60 Significant visual restrictions from frail older adults than in healthy persons. A recent cataracts may require cataract surgery to improve vision Cochrane review suggests that vitamin D reduced the and decrease fall risk. Maximizing vision in both eyes rate of falls but not fall risk in 4512 subjects living in appears to be critical.33 For macular degeneration in long-term-care environments.151 older adults, medication and careful observation by the ophthalmologist can slow the progression of macular Physical therapy interventions may play a restorative, degeneration. The physical therapist should determine if compensatory, or accommodating role in minimizing an older adult with a balance complaint has had an eye balance instability and decreasing risk of falls. Thera- examination within the last year and, if not, to be even peutic exercise is a primary restorative approach116,118,124; more vigilant to the possibility of an undetected eye footwear6 that provides increased sensory cues in the impairment as a possible contributor to the balance presence of decreased position sense serves as a compen- satory approach; and wearing hip protectors152 or using

CHAPTER 18  Balance and Falls 351 an assistive device148 serves an accommodating role. The responses, and very few people fall from the seated posi- physical therapist has a leading role in providing safe tion. It is also important to move the older adult beyond mobility training and in referral and collaboration with low-level elastic resistance exercise in order to use over- other health care providers to address all salient patient load principles to increase muscle strength.154 Often frail issues. Muscle strengthening, gait training, balance train- older adults will need more supervision to perform their ing, and flexibility or range of motion exercises are exercise program and move about the physical therapy all key ingredients for a successful physical therapy gym. Those older adults who are very frail in outpatient program to address balance deficits. settings may initially need to be seen more frequently so that they can be closely supervised during their exercise Individuals who are frail are at high risk for falling program. and can often benefit greatly from a comprehensive fall risk assessment and subsequent targeted interventions Balance Training that include physical therapy. Frail individuals have low physiological reserve and impairments across mul- One aspect of balance training focuses on exercises that tiple physiological systems, thus making them particu- improve the speed and accuracy with which the patient larly vulnerable to stressors.153 Figure 18-7 provides responds to unexpected perturbations via ankle, hip, examples of the many therapeutic interventions that stepping, or reaching strategies. Simple weight shifts in a should be considered for “frail” and “very frail” older safe environment with the hips and knees straight while adults. leaning forward and back may enable the person to more effectively choose an ankle strategy. Performing active The examination data regarding fear of falling needs leaning forward or back with resistance at the shoulders to be considered when developing and implementing the and then “letting go”43 (done carefully to protect the plan of care. The exercise environment and exercise ac- patient from falling) may be used as an intervention tivities should be structured to minimize fear while en- aimed at having patients practice executing an optimal suring adequate challenge to lead to improvements. postural control strategy when required. An option to Particular attention should be paid to home exercise train hip strategy response is to ask the patient to practice programs, as exercises that are perceived as too challeng- leaning forward at the hips while maintaining foot ing are less likely to be carried out because of fear of position (touch their nose to the mat table), or pulling the falling. For all except the extremely frail, it is essential patient off balance at the hip enough that they must lean that balance exercises be performed in upright stance in at the trunk to control their balance. order to adequately challenge balance responses. Seated balance exercises do little to affect standing balance Frail older adult Very frail older adult Strengthening Standing exercises Standing balance activities with supervision • Weight shifting (M/L, A/P, diagonal) Patient education about fall risk • Reaching while standing Environmental modifications • Bending Gait training • Lifting objects (different weights and heights) Assistive device modification (rollator walkers • Picking up objects off the floor are preferred to the standard walkers as people • Push and release to work on balance strategies are better able to walk at faster gait speeds) • Ankle and hip strategy training Stretching, especially the plantarflexors • Slow marching in place Strengthening, with emphasis of the toe flexors • Standing on various surface types in the lower extremity • Stretches of the plantarflexors Standing, weight shifts with supervision • Tai Chi Work to safely increase the velocity of walking Tai Chi or adaptations of the principles Gait training • Walking (increasing speed, as able) • Walk with different speeds • Walk and stop quickly on command • Walk with head movement (up/down, right/left) • Walk doing a secondary task • Walk on different surfaces FIGURE 18-7  I​llustrative ideas for physical therapy intervention based on the degree of frailty.

352 CHAPTER 18  Balance and Falls VOR in persons with vestibular dysfunction.161-163 It is thought that retinal slip drives the adaptation of Standing, standing with fast and slow weight shifts in the VOR.162 all directions, standing and reaching, standing with small pushes and then reaching for an object with a Standing balance and gait exercises that are progressed slight push would be an example of how to progress the in difficulty are provided to patients, including the follow- patient’s standing balance. During any weight shift, it is ing key concepts: (1) starting in more static and advancing important to teach the patient to better recognize where toward more dynamic movements164; (2) considering sub- their weight is under their feet. Activating distal sensa- ject learning style and key motor learning concepts such tion has been reported to be one of the possible reasons as knowledge of results and performance165; (3) increasing that Tai Chi may be successful in reducing falls in older the difficulty of the environment (closed to open skills, persons.155 Success is key when working with individuals quiet vs. busy environment)165; (4) varying from no head with balance deficits. One can always incorporate the movement to complex head movement during standing more difficult part of the exercise program in the middle, and gait165; (5) adding secondary tasks to the balance or ending the session with exercises that are a little less gait task (talking, holding/carrying, calculating)67; and challenging, thus boosting the patient’s confidence and (6) manipulation of the support surface (flat/stable surface sense of success. progressing to a dynamic surface [towel, foam pad, gravel, grass]).164 Any individual with a balance deficit can fall while performing a balance activity, so each patient must be Exercise Interventions: Strength, ROM, carefully assessed while performing each new activity in and Endurance order to determine the level of supervision necessary for adequate patient safety. To the extent that muscle strength, ROM, and aerobic Tai Chi.  T​ ai Chi (TC) is considered a balance training pro- endurance contribute to a patient’s instability, each needs gram because it contains slow movements that stress pos- to be addressed in the intervention program. Research tural control.156 TC can be performed in groups and re- indicates that lower extremity weakness is significantly quires the person to move body parts gently and slowly associated with recurrent falls in older adults,46,50 and that while breathing deeply. TC has a positive effect on balance improved lower extremity strength is associated with im- in older adults. Wolf et al demonstrated that the TC group provements in static and dynamic balance.166 Therefore, had a reduction in fear of falling, a decrease in risk of falls exercise therapy may be an effective strategy to increase by 47.5%, and lower blood pressure.156 Hakim et al found lower extremity strength and endurance, improve func- that greater balance ability was achieved in both the TC tional balance, and reduce fall risk. A multidimensional group and structured exercise group in a randomized con- training program that included stretching, flexibility, bal- trol trial.157 However, the multi-directional reach test ance, coordination, and mild strengthening exercise has (MDRT) scores from sitting position were significantly bet- demonstrated improvements in physical functioning and ter in the TC group. Richerson and Rosendale recorded oxygen uptake in community-dwelling older adults.167 distal sensation after TC exercise in older adults with dia- Similarly, a strength and balance training program betes and healthy older persons and found that both groups improved muscle strength, functional performance, and demonstrated improvements in their distal sensation.158 balance in older adults with a history of recurrent or inju- Vestibular Training.  ​Dizziness is never normal in older rious falls.168 Although it is clear that exercise is impor- adults. Persons with vestibular deficits (dizziness, light- tant to balance training, the optimal type, duration, and headedness, or vertigo complaints) benefit from exercise intensity of exercise programs are unclear.2,148 In general, and balance programs. Often older adults do not com- exercise programs should address static and dynamic bal- plain of spinning but may only report lightheadedness ance, coordination, strength, endurance, and ROM. Most during movement. Other conditions that cause dizziness exercise/balance programs that have demonstrated effec- must be ruled out to ensure that you are treating a tiveness lasted for greater than 10 weeks.2,148 Chapter 5 vestibular condition. Not all persons with vestibular provides a detailed discussion of general exercise princi- disorders have both dizziness and balance problems. The ples for the older adult. exercise program should specifically address the impair- ments and functional deficits noted. Assistive and Accommodative Devices The most common intervention for older adults is Ambulation devices, such as different types of canes and the use of the canalith repositioning maneuver (Epley walkers, may provide older fallers with greater stability maneuver) for benign paroxysmal positional vertigo and reduce risk of falling. These devices increase the (BPPV).159 Benign paroxysmal positional vertigo is ex- BOS in standing and walking by increasing the ground tremely common in older persons and reports of dizzi- contact. Ambulation devices may also help in reducing ness in people older than age 40 years are related to fear of falling by providing physical support and by add- reported falls.63 The canalith repositioning maneuver is ing tactile cues to enhance somatosensory contributions highly effective in resolving dizziness that is associated to postural control and sense of where the person is with a change of head position relative to gravity.160 Eye/head movements are often used with visual fixa- tion in order to attempt to normalize the gain of the

CHAPTER 18  Balance and Falls 353 in space.6,169 The proper ambulatory device can be bathmat can be used to reduce the risk of falling. prescribed according to older adults’ needs based on a Removal of rugs in the home is recommended to avoid comprehensive balance assessment. tripping and falling.175 The absence of grab bars in the tub/shower of older adults was found to be a dangerous Hip pads are most commonly used with patients in influence on the risk of falling.176 Therefore, adding grab nursing homes who are at very high risk for injury from bars in the tub/shower may have a beneficial effect on a fall. Hip pads have been shown to reduce the fracture reducing the number of falls. Handrails are also impor- rate marginally in older adults.6,152 Compliance is a tant to install to provide support for older adults. It is concern as the hip pads are somewhat cumbersome and very important to consider the angle and the diameter of unattractive worn under clothing. However, wearing hip the bar so that the installation of the grab bar is custom- protectors may provide psychological support for some ized for the person. older adults who are fearful of falling.6 Other modifications can be added to the bed and its Properly fitting footwear with a low heel and high surrounding area to provide support and prevent falls. sole/surface contact area also decreases the risk of fall- These modifications may include adjusting the height of ing. Because decline in distal somatosensory function the bed to be appropriate for the older adult, adding a with advanced age can lead to instability and increased slip-resistant footboard, and installing bedside rails.6 risk of falling, special insoles have been designed to en- The other area in the home that requires modifications hance somatosensory input. A facilitatory insole, as for older adults with balance and mobility problems is depicted in Figure 18-8, was recently shown to improve the bathroom. Toilet seat modifications may include lateral stability during gait and decrease the risk of fall- raising the seat or adding grab bars to help the older ing in older adults.170 Vibrating insoles have also been adult get on and off the seat safely.6 used to enhance sensory and motor function in older adults.171,172 The use of vibrating insoles demonstrated SUMMARY a large reduction in older adults’ sway during standing trials. Therefore, vibrating shoe insoles might contrib- Falls in older adults are a major concern and are a major ute to enhancing the stability of older adults during cause of morbidity and mortality. Falls are multifaceted dynamic balance activities.173 Gait variability in the and a heterogeneous problem. A comprehensive evalua- laboratory was reduced for older adults plus older fall- tion of pathophysiological, functional, and environmental ers while wearing the subthreshold vibratory device factors of falls is important for effective management. The during gait.174 goal of intervention should always be to maximize func- tional independence in a manner that moves the person Environmental Modifications up higher on the “slippery slope,” away from the line that indicates frailty and closer to the line that indicates “fun,” Environmental modifications may prevent falls and re- and to do this safely so that older persons can participate duce the risk of falling significantly. They also can serve in their community. as important adaptive strategies to promote mobility. Environmental modifications at home may include REFERENCES changes in lighting, floor surfaces, handrails, bed, and the bathroom.6 Certain locations at the home or in the hos- To enhance this text and add value for the reader, all pital need extra lighting, especially at night such as the references are included on the companion Evolve site bedside area, the path to the bathroom, and in the bath- that accompanies this text book. The reader can view the room. Lack of slip-resistant surfaces contributes to high reference source and access it online whenever possible. fall rates.128 Therefore, it is helpful to identify risky floors There are a total of 176 cited references and other gen- and to modify surfaces that can make them safer. In the eral references for this chapter. bathroom, for example, a slip-resistant surface or nonslip Figure 18-8  ​An insole that provides increased lateral cues to older adults when they move close to their limits of medial/lateral stability. (From Perry S, Radtke A, Mcllroy W, et al: Efficacy and effectiveness of a balance-enhancing insole. J Gerontol 63A:595-602, 2008.)

IVP A R T Special Problems and Interventions 354

19C H A P T E R Impaired Integumentary Integrity John Rabbia, PT, DPT, MS, GCS, CWS INTRODUCTION impairments most typically occur when the demand of extrinsic stresses plus the presence of comorbid health Skin and wound care is a dynamic, ever-evolving field par- conditions are added to normal aging. ticularly in relationship to the management of older adults. Physical therapists are vital members of the skin and The skin is composed of two main layers, the epider- wound care team. Physical therapists bring a specialized mis and the dermis, with a basement membrane separat- and unique body of knowledge and skills that contribute ing the two layers (Figure 19-1). The epidermis is the to the team’s ability to benefit the older adult patient. thin outermost layer of the skin composed of five sublay- ers. From deep to superficial, the five sublayers of the Advanced age, by itself, is not a risk factor for impaired epidermis are the stratum germinativum, stratum spino- integumentary integrity. However, several comorbid con- sum, stratum granulosum, stratum lucidum, and stratum ditions more common in older adults are also commonly corneum. The two main functions of the epidermis are associated with integumentary impairments (e.g., diabetes moisture retention and protection of deeper structures. and arterial insufficiency). These comorbid conditions put The epidermis regenerates every 4 to 6 weeks and does older adults at higher risk for integumentary impairments. not have a blood supply. With normal aging, the epider- With diligent care and effective prevention and educa- mis thins and decreases in density of Langerhans cells. tional interventions, most older adults with conditions Langerhans cells initiate the immune response when for- that put them “at risk” for integumentary impairments eign cells are present. Consequently, with decreased can enjoy intact skin into oldest age. thickness and immune function, the epidermis becomes less effective at protecting the body from infection and This chapter begins with a discussion of normal age- dehydration.1,2 The basement membrane is the interface related changes in skin and selected skin conditions between the epidermis and dermis. The basement mem- prevalent in older adults. The chapter continues with an brane is composed of many projections of the dermis examination of normal wound healing in older adults into the epidermis. These projections are known as rete and factors that can delay wound healing, followed by a pegs and they provide resistance to shearing forces discussion of the role of the physical therapist as a mem- between the epidermis and dermis. The basement mem- ber of the wound care team. brane also thins with age because of a flattening of the rete pegs, and this increases vulnerability to shear-related Five distinctly different categories of wounds are pre- insults to the skin.2-4 sented, each with a distinct etiology and management approach: skin tear, pressure ulcer, venous insufficiency The dermis is the thick, deeper layer of the skin respon- ulcer, arterial insufficiency ulcer, and diabetic ulcer. sible for structural integrity of the integument. The dermis The steps of the physical therapist patient management provides nutrition, hydration, and oxygen to the epidermis process—examination, evaluation, diagnosis, prognosis, via diffusion. The dermis is primarily composed of the intervention, and outcome assessment—are applied to protein collagen, which provides tensile strength, and elas- each wound category. The chapter ends with a detailed tin, which allows the skin to stretch. Collagen and elastin discussion of interventions used by physical therapists to are produced by fibroblasts. As fibroblasts decrease with manage patients with integumentary conditions. age, so too does the rate of production of collagen and elastin. Elastin fibers become degraded while collagen NORMAL AGING-RELATED CHANGES bundles become disorganized.2,3,5 The dermis also thins as IN THE SKIN a normal consequence of aging with fewer blood vessels and nerve endings. As the blood vessels in the skin become As with other organs in the body, the skin undergoes thinner, they are more prone to hemorrhages known as changes with aging. However, these changes do not typically cross the threshold of impairment. Integumentary-related Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 355

356 CHAPTER 19  Impaired Integumentary Integrity Stratum corneum EPIDERMIS FIGURE 19-2  Xerosis. (From Ignatavicius DD: Medical-surgical Basement membrane Papillary nursing: patient-centered collaborative care, ed 6, Saunders, dermis Philadelphia, 2009.) with rete pegs Sweat duct DERMIS below 10%.1,9 The precise cause of xerosis is not known; Capillary Reticular however, age-related changes as well as environmental Sebaceous dermis and genetic factors contribute to the severity of this prob- gland lem. Xerosis can negatively impact the quality of life for SUBCUTANEOUS older adults by producing pruritus (itching), burning, or Nerve TISSUE stinging, and an uncomfortable sensation of tightness in endings the skin. As xerosis becomes more severe, it can lead to redness or cracking of the skin.1 Older adults should be Hair encouraged to keep hydrated and to use a moisturizing follicle lotion to prevent or manage dry skin. Cellulitis.  C​ ellulitis, illustrated in Figure 19-3, is a rapidly Hair spreading infection of the dermis and subcutaneous layer bulb most commonly seen in the face and extremities. Typically, Sweat cellulitis occurs at a site where the skin has been broken: gland cracks, cuts, blisters, insect bites, burns, injection sites, Fat Blood vessels FIGURE 19-1  Layers of the skin and its underlying tissue. (From Goodman CC: Pathology: implications for the physical therapist, ed 3, Saunders, Philadelphia, 2008.) senile purpura. Senile purpura are often the site of skin tears, possibly due to a decrease in pain perception in the area of the purpura.1,6 Finally, pacinian and Meissner cor- puscles found in the dermis degenerate with normal aging and contribute to decreased perception of light touch and pressure sensation. Below the dermis is the subcutaneous layer, composed mainly of adipose tissue but also consisting of blood and lymphatic vessels as well as nerves. The subcutaneous layer facilitates regeneration of the dermis by providing blood supply and it also connects the dermis to underly- ing structures. As with the more superficial layers of the skin, the subcutaneous layer becomes thinner with age and diminishes in its ability to provide mechanical protection and thermal insulation.1,2 Lifestyle considerations, particularly sun exposure and cigarette smoking, have an aging effect on skin, including the formation of wrinkles, hyperpigmentation, and change in skin texture. The most significant extrinsic cause of skin degeneration is photoaging, that is, the effect of exposure of the skin to ultraviolet irradiation. The effects of photoaging are seen only in areas of the body exposed to the sun, primarily the face, neck, and hands.1,7 Ciga- rette smoking has been shown to increase the incidence of skin wrinkling in smokers when compared to similarly aged nonsmokers. Although the exact cause for increased wrinkling is unknown, it is believed to be a consequence of the cigarette smoke’s toxicity on microvasculature as well as a negative effect on oxidative and enzymatic activ- ity in connective tissue in the dermis.1,8 Skin Conditions FIGURE 19-3  Cellulitis. (From Gould BE: Pathophysiology for the Xerosis.  T​ he incidence of xerosis, or dryness of the skin, health professions, ed 3, Saunders, Philadelphia, 2006.) increases as people age. Xerosis, depicted in Figure 19-2, occurs when the moisture level of the stratum corneum is

CHAPTER 19  Impaired Integumentary Integrity 357 surgical incisions, and catheter insertion sites. The infec- infections of wounds can be treated with topical agents tion can be caused by the normal flora of the skin but may such as silver-containing dressings. also be caused by exogenous bacteria, most commonly, Herpes Zoster.  H​ erpes zoster, also known as shingles, is group A Streptococcus or Staphylococcus. Signs and symp- illustrated in Figure 19-4. Herpes zoster results from the toms of cellulitis include pain, increased warmth, ery- reactivation of the varicella zoster virus, which lies dormant thema, and edema. Older adults are at higher risk for in nerve ganglia after chickenpox. Age is one of the most cellulitis in the presence of edema, obesity, and openings in significant risk factors for developing shingles, with re- the skin.1,10 When edema is present anywhere in the body, ported prevalence of 6.9 cases per 1000 in people aged 60 there is a higher risk of cellulitis in that area, and obese to 69 and increasing to 10.9 cases per 1000 in people older people are at highest risk for cellulitis in the folds and rolls than age 80 years.14 Shingles can be identified by com- of the skin. The prevalence of cellulitis has been reported plaints of tingling or pain in a unilateral dermatome fol- as high as 32% for people aged 65 or older who have been lowed in 1 to 2 days by erythema and vesicles. The vesicles admitted to the hospital.11 Cellulitis is most commonly break down into crusted plaques, and patients remain con- treated with oral antibiotics but in severe cases, intrave- tagious for chickenpox until all of the vesicles have crusted nous antibiotics may be considered. over. It typically takes 2 to 3 weeks from the initial onset of Methicillin-Resistant Staphylococcus aureus.  M​ ethicillin- dermatomal pain to the resolution of the zoster plaques.15 resistant Staphylococcus aureus (MRSA) is a strain of Shingles occurs most commonly in the thoracic, cranial, antibiotic-resistant bacteria growing more and more lumbar, and sacral dermatomes. Once identified, shingles prevalent in the United States and around the world. are treated with oral antiviral agents such as valacyclovir Older adults are three times more likely to be hospital- and famciclovir to minimize the duration of the disease and ized with MRSA infections than any other age group; incidence of postherpetic neuralgia (PHN).1,16 Areas of skin hospitals and long-term-care settings are known as affected by vesicles can be treated by topical application of major locations where MRSA infections originate.1,12 emollients, and PHN symptoms are commonly managed Although hospital-acquired MRSA typically results in through oral agents such as gabapentin and tricyclic antide- systemic infections, community-acquired MRSA most pressants.1 Physical therapists may be involved in the man- often leads to infections of the skin and soft tissue. Pa- agement of PHN. tients with skin infections comprise the greatest percentage (19%) of MRSA cases.1,13 Systemic MRSA Candida.  ​Candida, illustrated in Figure 19-5, is a infections are treated with oral or intravenous antibiotic superficial yeast infection that most commonly affects medications to which MRSA is not yet resistant; localized older adults and the immunocompromised. Candida presents most often in the groin, axilla, or breast folds; FIGURE 19-4  Herpes zoster. (From Goodman CC: Pathology: implications for the physical therapist, ed 3, Saunders, Philadelphia, 2008.)

358 CHAPTER 19  Impaired Integumentary Integrity FIGURE 19-5  Candida. (From Gould BE: Pathophysiology for the Skin Cancer health professions, ed 3, Saunders, Philadelphia, 2006.) The three most common types of skin cancer include basal cell carcinoma, squamous cell carcinoma, and affected skin may appear macerated and erythematous melanoma. Although melanoma is less common than with papules and pustules. Standard treatment for can- basal or squamous cell carcinoma, it is more deadly. dida consists of topical antifungal agents alone or in Risk factors for skin cancer include men and women combination with topical steroids.1 older than age 65 years, patients with atypical moles, Scabies.  S​ cabies, illustrated in Figure 19-6, is very conta- patients with more than 50 moles, family history of skin gious and common to long-term-care and other settings cancer, and a history of severe sunburns. Patients should where people live in close proximity with each other. The be educated in the signs of a suspicious lesion, which incidence of scabies has been reported as high as 25% for include asymmetry, border irregularity, diameter greater residents of long-term-care institutions.17 Scabies is caused than 6 mm, or a rapidly changing lesion. Figure 19-7 by a mite that lays its eggs in burrows on the skin. In 3 to illustrates a skin cancer. The signs of a suspicious lesion 4 days the larvae hatch, come to the skin, and repeat the can be remembered with the mnemonic device ABCD: process. Several weeks after the initial infection, itching asymmetry, border, color, and diameter. Current recom- will be reported as a result of the immune response to the mendations state that any lesion that demonstrates mites and their wastes; once the itch is scratched a second- malignant tendencies should be biopsied.20 ary infection may result. Scabies infections can be recog- nized by excoriation and papules around the groin, abdo- WOUND HEALING PROCESS men, axillae, and wrists. Scabies often goes undetected in cognitively impaired older adults because of the inability Normal Healing to report symptoms. Treatment for scabies includes a topical scabicide such as permethrin, and all bed linens In the healthy older adult, wound healing takes little, should be washed in the hottest possible water (i.e., 140° if any, more time than it does in younger people. In fact, to 200° F or 60° to 90° C).1,18,19 in older adults, the final scar may be of higher quality under microscopic evaluation compared to younger adults.21,22 The inflammatory phase of wound healing com- mences immediately after the wound is acquired and lasts for the next 2 to 5 days. The body’s initial response to trauma is to limit the extent of the injury by achieving homeostasis. Vasoconstriction limits circulation to the area while platelets aggregate and thromboplastin facili- tates the formation of a clot. Polymorphonuclear neutro- phils release proteolytic enzymes to break down dam- aged tissue, phagocytize bacteria and tissue debris, and release cytokines along with mast cells and lymphocytes; cytokines act as chemical mediators to progress the wound into the proliferative phase of healing.23 The proliferative phase of wound healing begins the transition from injury to closure on or near postinjury day 2 lasting until postinjury week 3. The polymorphonuclear FIGURE 19-6  Scabies. (From Christsensen BL: Adult health nursing, FIGURE 19-7  Melanoma. (From Goodman CC: Pathology: impli- ed 5, Mosby, St. Louis, 2005.) cations for the physical therapist, ed 3, Saunders, Philadelphia, 2008.)

CHAPTER 19  Impaired Integumentary Integrity 359 neutrophils degrade and are engulfed and replaced by thin, friable type III collagen is slowly replaced with macrophages, which carry on the task of phagocytizing stronger type I collagen. Collagen cross-linking increases bacteria and debris while also releasing chemical media- the tensile strength of the wound, although the final tors that further guide the wound healing process. During resulting scar is only 80% as strong as the initial tensile the proliferative phase fibroblasts migrate to the wound strength of the original tissue.23 bed and lay down an extracellular matrix of mainly type III collagen and elastin; shortly thereafter, angiogen- Factors That Delay Wound Healing esis leads to the formation of new capillaries in the wound bed. This new tissue, called granulation tissue, has a Although the basic wound healing process does not raspberry-like texture and appearance. While granulation change in older adults, the lower physiological reserve of tissue is forming and capillary beds become established, older adults combined with the increased prevalence of myofibroblasts migrate to the wound edges; myofibro- comorbid conditions associated with delayed wound blasts are fibroblast cells that have an actin–myosin healing make the older adult more susceptible to factors complex and are able to contract like a smooth muscle that delay wound healing and increase rates of wound cell. Myofibroblasts contribute to wound healing by con- infection.24 Wound healing can be delayed by many tracting the wound edges toward the center of the wound, factors.23,25,26 Some of these factors are intrinsic, mean- decreasing the total surface area of the wound base. Once ing they emerge from internal physiological abnormali- the wound defect has filled in with granulation scar tissue ties that impair effective wound healing. Other factors from the bottom up, epithelial cells derived from hair are extrinsic, meaning they arise from external forces follicles and sweat glands migrate from the edges toward deterring normal healing processes. Box 19-1 provides a the center to close the wound over. If the wound base is list of common intrinsic and extrinsic factors associated not kept moist, epithelialization takes a significantly with delayed wound healing. longer period of time as the epithelial cells must burrow underneath the desiccated tissue instead of migrating If the cascade of events and reactions that lead to across the moist wound base.23 In normal aging, the pro- wound healing fail to occur in a timely and predictable cess of epithelialization occurs at about the same rate as manner, the wound may become chronic. This is usually that of younger adults and results in a scar that has similar an indication of the presence of infection or other tensile strength.22 foreign matter in the wound. Chronic wounds have been known to have an excess of proteolytic enzymes called From week 3 through the 2 years the wound under- matrix metalloproteinases (MMPs) and a paucity of pro- goes the process of maturation or remodeling when the teinase inhibitors,21 which leads to an imbalance in the B O X 1 9 - 1 Common Intrinsic and Extrinsic Factors Associated with Impaired Wound Healing Intrinsic Factors Extrinsic Factors Immobility Tobacco use Impaired nutrition Pressure that impairs circulation in area Impaired hydration Desiccation, leading to scab or crust Obesity Presence of necrotic tissue (eschar or slough) Cachexia Repetitive trauma causing high shear forces Infection or colonization Maceration (typically from incontinence or perspiration) Edema around the wound (inhibits Lack of participation in wound plan of care oxygen and nutrient transport) Decreased circulatory function Decreased respiratory function Immunosuppressed state (including use of corticosteroids and NSAIDs) Radiation therapy Chronic diseases such as: Diabetes PAD/PVD CAD Renal failure Anemia Cancer End of life CAD, coronary artery disease; NSAID, nonsteroidal antiinflammatory drug; PAD, peripheral arterial disease; PVD, peripheral vascular disease.

360 CHAPTER 19  Impaired Integumentary Integrity deposition and degradation of collagen in the formation in this chapter. When patients experience a loss of 10% of the extracellular matrix. of LBM, wound healing is impaired; with a loss of 20% to 30% of LBM, the risk of developing new wounds Nutrition, Hydration, and Wound Healing increases and healing stops in existing wounds.29 The role of nutrition in the prevention and treatment Older adults are at greater risk of dehydration than of wounds in older adults is the source of some contro- younger people and this can lead to serious health compli- versy with respect to specific measures and supplements. cations including increased time to wound healing, espe- What is clear is that poor nutrition increases risk of im- cially with regard to pressure ulcers. It is generally ac- paired integumentary function; and adequate nutrition cepted that the increased risk of dehydration among older decreases the risk of integumentary insult and enhances adults is not a direct consequence of aging but rather the healing of existing wounds. A dietician should be con- result of age-associated factors such as increased physical sulted for any older adult who is at risk for, or who has, dependence and multiple medical comorbidities.30,31 Clini- impaired integumentary status.27 cal assessments of dehydration may include dry mucous membranes, rapid pulse, furrowed tongue, and decreased Older adults are susceptible to a host of intrinsic and upper extremity strength. The commonly accepted test of extrinsic factors that may lead to malnutrition, increased skin turgor at the sternum is not reliable in older adults risk of developing new wounds, and impaired ability to because of the previously discussed changes in skin elastic- heal existing wounds. Changes in the digestive system of ity.30,32,33 Other measures of dehydration are obtained older adults include decreased production of digestive from lab values, including increased levels of serum enzymes and acids, which leads to decreased absorption sodium, increased serum osmolality, and increased ratio of of nutrients. Impaired dentition may lead to difficulty blood urea nitrogen to creatinine.34 with chewing, and dry mouth may lead to difficulty swallowing. Chronic illness or impaired mobility can Nutritional Supplementation decrease the ability of older adults to shop, cook, or eat to Support Wound Healing independently. Impaired mental function can suppress appetite, as can many medications, including antidepres- Standard recommendations for nutritional intake in- sants, blood pressure medications, and even over-the- clude 1.0 to 1.5 g of protein per kg of body weight per counter medications such as aspirin. Older adults may day and 35 to 40 kcal per kg of body weight per day. also have a decreased sense of taste and smell, both of Many powdered and liquid supplements are available to which can significantly decrease appetite. Other extrinsic augment oral intake of protein. Many supplements also risk factors for malnutrition in older adults include low include arginine and glutamine, both amino acids that or fixed income, depression, social isolation, and dietary increase protein synthesis when the body is under restrictions necessitated by other comorbidities.28 stress.34,29 Supplemental vitamin C (1 to 2000 mg/day), zinc (50 mg four times a day), and trace mineral supple- The presence of a wound or infection significantly ments should be considered to promote wound heal- increases the body’s consumption of calories and pro- ing.35-38 Vitamin C is a water-soluble vitamin that in- tein. During the inflammatory response to injury or creases fibroblast proliferation, therefore increasing infection, metabolic activity increases and protein and collagen synthesis. Vitamin C also plays a role in leuko- glycogen stores are released to meet the increased cyte phagocytosis of bacteria in the wound bed. Zinc, a demand for glucose and stress factors such as cytokines trace mineral, is necessary for protein digestion and syn- and interleukins. Cytokines are cell-mediated proteins thesis. Zinc also plays a role in immune function and that enhance the immune response to injury but also collagen synthesis. Zinc levels can be depleted through accelerate catabolism, which can rapidly deplete the excess wound drainage. However, zinc supplementation body’s protein stores. As the body’s stores of protein are should be provided on a short-term basis only because depleted, so too are skeletal muscle strength, immune excess zinc levels can also delay wound healing.34,29 system function, bowel function, and wound healing.29 Anemia commonly requires supplementation to correct the subsequent deficiencies in hemoglobin and hemato- When nutritional intake is inadequate to support the crit, which are essential for the transport of oxygen to cascade of inflammatory and immune system responses the wound bed. Different forms of anemia are identified to injury, lean body mass (LBM) is lost and protein- through blood tests and treated with differing supple- energy malnutrition (PEM) may result. Patients with ments. Anemia of chronic disease with iron deficiency is PEM are at increased risk of developing new wounds treated by a multivitamin with iron. Folate deficiency and will experience delays in healing of existing wounds. anemia is the result of decreased folate absorption It is important to note that malnutrition or risk of mal- and liver disease and is therefore treated with folate nutrition is present in 40% to 60% of hospitalized older supplementation. Pernicious anemia requires vitamin B12 adults in the United States. The cardinal signs of PEM supplementation.34 Nutritional interventions, like all are involuntary weight loss with a decrease in functional wound interventions, should be evaluated regularly by a protein stores. Protein levels are measured with blood tests for serum albumin and prealbumin, discussed later

CHAPTER 19  Impaired Integumentary Integrity 361 qualified professional and modified as needed to facili- and repositioning techniques, making recommendations tate the best possible outcomes. for adaptive equipment and the fabrication of splints to assist with wound prevention and healing. Enteral nutrition has not been shown to improve outcomes when attempting to improve nutritional status As part of every initial physical therapy evaluation, the in people with wounds.27 physical therapist should perform a screen of the integu- mentary system with subsequent referral out or manage- ROLE OF PHYSICAL THERAPIST IN THE ment, as appropriate, if an integumentary concern is WOUND CARE TEAM ACROSS SETTINGS identified. Physical therapy management may include risk assessment, recommendation for appropriate support sur- The wound care team typically consists of the patient, any faces or adaptive equipment, and the prescription of tar- involved family members or caregivers, physicians, nurses, geted exercise to promote wellness and prevent impair- aides, dietician, physical therapists, and occupational thera- ment to the integumentary system. In cases of chronic pists. The patient is the most critical member of the wound wounds or those that need more advanced treatment tech- care team as he or she ultimately determines the extent of niques, the physical therapist may use physical agents or the goals for treatment and must participate actively in the other modalities to facilitate wound healing. plan of care. Family members and other caregivers are in- tegral in providing encouragement and consistency with the SKIN TEARS necessary interventions. It is of utmost importance that patients and caregivers have a basic understanding of the Epidemiology significance of different interventions in order to ensure full and willing participation in the recommended interven- Skin tears, the traumatic separation of the epidermis tions. For instance, if a caregiver does not possess at least a and dermis, occur with the greatest frequency in adults cursory understanding of the concept of shear, he or she aged 65 years and older.1,6 Institutionalized adults suffer may continue to use less than optimal technique, thus in- 1.5 million skin tears per year.1,36,39 Older adults may flicting damage on a pressure wound while assisting the experience skin tears anywhere on the body, though the patient in transfers or repositioning. most common locations are the arms and hands, followed by the lower extremities1,36 (Table 19-1). Physicians provide medical oversight for the plan of care and authorize any interventions that require a phy- Risk Factors and Injury sician’s order. Nurses typically perform routine risk Prevention Strategies assessments, skin assessments, and wound and dressing care. Aides serve an important role as the “eyes and The risk of skin tears increases with dependence in activi- ears” of the wound care team. Aides frequently have ties of daily living and with the removal of tapes and more direct contact with patients than any other mem- adhesives from the skin.1,38 Any activity that increases the ber of the wound care team and may be the first person risk of imposing a shear force on the skin, such as assisted to notice changes in the patient’s integumentary integrity transfers in and out of wheelchairs or tub chairs, increases or changes in function, such as mobility, continence, or the risk of skin tears. Visual impairment increases the risk nutritional intake that put patients at risk for skin break- of skin tears because of bumping into objects.1,36,40 down. Dieticians perform nutritional risk assessments and may make recommendations for nutrition and Preventing skin tears means protecting the skin from hydration interventions to prevent or facilitate healing of trauma. Older adults should be encouraged to avoid skin impairments. Physical or occupational therapists soaps and lotions containing alcohol, apply lotion twice may be involved in training caregivers in proper transfer per day, wear loose, long-sleeved shirts and pants, and TA B L E 1 9 - 1 Payne-Martin Skin Tear Classification System39,40,206 Category Amount of Tissue Loss Description I Skin tear without tissue loss Linear type (epidermis and dermis layers separated in an incision-like lesion) Flap type (an epidermal flap that covers the dermis, and wound edges are within 1 mm width) of separation II Partial tissue loss Scant tissue loss: ,25% epidermal flap lost Moderate to large tissue loss: .25% epidermal flap lost III Skin tears with complete Epidermal flap completely gone tissue loss

362 CHAPTER 19  Impaired Integumentary Integrity skid-free footwear.36,38,40-42 The environment can be remain in place against the chair or bed. When shear is modified to limit risk of skin tears by eliminating super- present, smaller blood vessels are distorted and therefore fluous furniture, providing adequate lighting (including less pressure is needed to cause occlusion and subsequent night-lights), and padding edges on furniture, wheel- tissue hypoxia.36 Friction, in combination with pressure chairs, and bedrails.36,40,43 Caregivers and institutions and shear, is also associated with the development of should be educated in proper transfer technique to pre- pressure ulcers.51 Friction is a mechanical force that vent friction, shear, or trauma and should use gauze occurs when two surfaces move across one another. Fric- wrap or stockinette to secure dressings instead of apply- tion creates heat and may cause an abrasion. Friction can ing tape or other adhesives directly to skin.36,39,40,42,43 be caused when a patient transfers but does not fully clear the surface of the bed or chair, causing skin to be PRESSURE ULCERS dragged along that surface. Epidemiology Pressure ulcers have traditionally been described as Stage I, II, III, or IV depending on the depth of tissue Although older adults are not at higher risk for pressure destruction. In 2007, the National Pressure Ulcer Advi- ulcers simply as a consequence of advancing age, the sory Panel released an updated staging system54 with increased prevalence of pressure ulcer risk factors, such several new descriptions to allow more accurate differ- as impaired mobility and frailty, are more common in entiation between existing stages and to provide more older adults. The prevalence of pressure ulcers among precise descriptions of ulcers that cannot be completely older adults varies widely within and among setting; visualized because of the presence of nonviable tissue. 3.5% to 29% in acute care/hospital settings; 2.4% to This staging system, with definitions of each stage, 26% in long-term care settings; and 10% to 12.9% in is displayed in Table 19-2. The four major stages of a home health care settings.36,44,45 The 2009 national pressure ulcer are depicted in Figure 19-8. prevalence of pressure ulcers for long-stay nursing home residents is 12% for those at high risk for developing As the name suggests, a wound staged at “suspected pressure ulcers, and 2% for those at low risk. The deep tissue injury” indicates suspicion of damage to deep prevalence of pressure ulcers for short-stay residents is 14% and was not differentiated by high versus low TABLE 19-2 National Pressure Ulcer Advisory risk.46 The presence of chronic pressure ulcers is associ- Stage Panel Pressure Ulcer Stages54 ated with increased 6-month mortality among nursing Suspected deep home residents.47 The cost of treating a pressure ulcer Description has been estimated as low as $500 to as high as $50,000 tissue injury in severe cases.48 Although prevention of pressure ulcers Purple or maroon localized area of discolored is a significant concern for facilities that strive to limit Stage I intact skin or blood-filled blister due to patient suffering and cost, it has become a particularly damage of underlying soft tissue from important goal because pressure ulcers have been defined Stage II pressure and/or shear. The area may be as an avoidable adverse event and Medicare limits reim- Stage III preceded by tissue that is painful, firm, bursement for costs incurred as a result of hospital- mushy, boggy, warmer, or cooler as acquired pressure ulcers.49 Similarly, long-term care fa- Stage IV compared to adjacent tissue. cilities can be fined a maximum penalty of $10,000/day Unstageable for facility-acquired or deteriorating pressure ulcers.48 Intact skin with nonblanchable redness of a localized area usually over a bony Etiology prominence. Darkly pigmented skin may not have visible blanching; its color Pressure ulcers occur when soft tissue is subjected to pres- may differ from the surrounding area. sure and shear forces, particularly over a boney promi- nence. Once compressed, the soft tissue becomes hypoxic Partial-thickness loss of dermis presenting as a and, eventually, necrotic.36,50-52 The amount and duration shallow open ulcer with a red-pink wound of pressure that soft tissue can tolerate prior to the devel- bed, without slough. May also present as an opment of a pressure ulcer varies based on the amount of intact or open/ruptured serum-filled blister. shear force present and general health status of the per- son. Shear is a tearing force that causes boney structures Full-thickness tissue loss. Subcutaneous fat may to move in the opposite direction of the overlaying be visible but bone, tendon, or muscle are tissue.53 Shear can result from positioning in a chair or not exposed. Slough may be present but bed, particularly when the head of the bed is elevated does not obscure the depth of tissue loss. higher than 45 degrees, causing the patient’s deeper tis- May include undermining and tunneling. sues to slide down while the skin and superficial tissues Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

CHAPTER 19  Impaired Integumentary Integrity 363 Stage I Stage II Stage III Stage IV Unstageable Suspected deep tissue injury FIGURE 19-8  The stages of pressure ulcers: Stages I through IV plus unstageable and suspected deep tissue injury. “Reproduction of the National Pressure Ulcer Advisory Panel (NPUAP) materials in this document does not imply endorsement by the NPUAP of any products, organizations, companies, or any statements made by any organization or company.” structures. However, the overlying skin is intact, thus a blister, it can be more difficult to stage this wound. The only allowing assessment of surface discoloration and general view among experts in the wound care field is not direct observation of a potential underlying wound.54 that a serum-filled blister represents a stage II pressure As the ulcer evolves, differences in pain, texture, and ulcer. However, a blood-filled blister is indicative of temperature of the affected area compared to adjacent damage that extends beyond the dermis and therefore is tissues will become evident. Ultimately, suspected deep classified as a suspected deep tissue injury, not a partial- tissue injuries may evolve into an open pressure ulcer thickness stage II ulcer.54 that can be staged by direct observation. The intact skin overlying both suspected deep tissue injury pressure A stage III pressure ulcer is a full-thickness tissue loss. ulcers and stage I pressure ulcers makes it more difficult Although subcutaneous tissue may be visible, bone, ten- to discern wounds in individuals with darker skin tones. don, and muscle are not.54 Many clinicians struggle to In this situation, the clinician should observe for subtle differentiate stage II and stage III pressure ulcers because differences in skin tone around the suspected wound the differences between the two stages can be subtle. in addition to gently palpating for differences in tissue There are several tell-tale differences between the two temperature and texture compared to surrounding skin. stages that clinicians should keep in mind. Stage II pres- Complaints of pain or altered sensation over a boney sure ulcers are shallow because they are, by definition, a prominence should also trigger suspicion of potential partial-thickness wound. Stage II pressure ulcers do not tissue injury. present with slough, necrotic tissue, or undermining/ tunneling; if any of these factors are present, the wound Stage II pressure ulcers extend through the dermis but is at least a stage III ulcer. A stage IV pressure ulcer has not to subcutaneous tissues. If the wound is covered by clear evidence of full-thickness tissue loss and may have

364 CHAPTER 19  Impaired Integumentary Integrity undermining, tunneling, slough, and/or eschar. Wounds prevalence of fecal incontinence in adults age 65 years and must be described as “unstageable” when the wound older is 3.1%.63 Prevalence of urinary incontinence in- base is completely obscured by slough or eschar. creases with increased body mass index (BMI) and cogni- Necrotic tissue must be removed before the wound can tive impairment,63,64 whereas risk of fecal incontinence be accurately staged. increases with hospitalization and immobility.1,65 It is important to note that pressure ulcers cannot be There are several pressure ulcer risk assessment tools, “reverse staged” to indicate healing. That is, a stage IV and each option uses subscales to measure various aspects pressure ulcer cannot be called a stage III pressure ulcer of an individual’s risk of developing pressure ulcers. No once it heals to the extent that bone, tendon, or muscle evidence exists to support the use of one tool over an- is no longer exposed. Reverse staging would indicate other.66 The most commonly used pressure ulcer risk as- that the tissues destroyed when the pressure ulcer formed sessment tools include the Braden,56 Norton,59 Gosnell,58 have been replaced. In reality, when a pressure ulcer and Waterlow57 scales. Subscales vary by tool but gener- heals, the void is filled with granulation, or scar tissue. ally include factors that increase risk of pressure ulcer. The The correct indication of pressure ulcer improvement Gosnell and Waterlow scales include other data such as would be to document a “healing,” or “resolving” pres- medications and vital signs that do not contribute to the sure ulcer of the appropriate stage. Once the pressure risk assessment score but are important components of a ulcer is completely reepithelialized it is still known as comprehensive patient examination. According to current a “healed,” or “resolved,” pressure ulcer because the literature regarding validity, the Norton scale sacrifices underlying tissue is composed of scar tissue rather than sensitivity for a high degree of specificity. The Braden the original subcutaneous fat, muscle, tendon, etc. scale offers a high degree of specificity and sensitivity at a Furthermore, should the healed pressure ulcer reopen, it cutoff score of 16.67 must be documented at its previous stage. For example, if a stage IV pressure ulcer heals (and is then known as The most important aspect of completing a risk a healed stage IV pressure ulcer) but then reopens, it is assessment is to use the information to develop an indi- immediately staged as a stage IV pressure ulcer, regard- vidual plan of care to prevent the development of pres- less of the extent of tissue destruction.55 sure ulcers. Although many scales have an overall “cut-off” score at which the individual is considered Pressure Ulcer Risk Factors “at-risk,” each subscale can be used as an opportunity to and Wound Prevention Strategies identify an area that might warrant intervention. Table 19-3 summarizes key features of each of these four As the name implies, pressure ulcers are caused by pres- scales. The National Pressure Ulcer Advisory Panel sure, and therefore, any factor that increases the inten- (NPUAP) recommends that all patients be risk assessed sity or duration of pressure on living tissue can be a risk on admission, and that ongoing periodic reassessment factor for developing a pressure ulcer. Immobility, lead- differs by setting. In the acute care settings, patients ing to prolonged pressure, friction, and shear, is the most should be reassessed every 24 hours, and more fre- widely known risk factor for pressure ulcers56,57 and quently if there is a change in condition. In long-term one that can be most effectively mitigated through care settings, periodic reassessment should occur weekly physical therapy. Other risk factors for pressure ulcers for the first 4 weeks and then quarterly, and with any include impaired sensation,56 impaired nutrition,56-58 change in condition. In the home care setting, patients cognitive impairment,58,59 and increased exposure to should be reassessed at every nurse visit.51 moisture,1,35,56-60 such as from incontinence of bowel or bladder. General Approaches to Pressure Ulcer Management Although urinary incontinence has not been conclu- sively linked to increased risk of pressure ulcers,1 it is The most fundamental and vital aspect of preventing or well documented that exposure to moisture such as urine treating pressure ulcers is to identify “at risk” can cause skin to be more susceptible to friction and patients and mitigate sources of increased pressure. Uti- other injury.35,60 Both urinary and fecal incontinence can lization of risk assessment tools provides insights into increase risk of dermatitis and cellulitis,1 whereas fecal primary contributors of risk and the overall amount of incontinence is a more significant risk for skin break- risk. From this risk assessment, a comprehensive, indi- down because of the irritation resulting from destructive vidualized plan of care can be developed and carried out enzymes in the feces.60,61 by the appropriate members of the multidisciplinary wound care team.51,60,68 Recommendations for preven- Urinary and fecal incontinence are not a normal conse- tion and treatment of pressure ulcers include use of mild quence of aging. However, both become more common cleansing agents when bathing, establishing a bowel and with increasing age as a result of increasing comorbidities bladder program for incontinent patients, avoiding mas- that predispose older adults to being incontinent.62 Overall sage over boney prominences, maximizing nutritional prevalence of urinary incontinence in adults age 65 years status, and educating caregivers at all levels of care. and older has been reported to be 11.6%; overall

CHAPTER 19  Impaired Integumentary Integrity 365 TABLE 19-3 A Comparison of Four Scales to Assess a Patient’s Risk of Developing a Pressure Ulcer Items included Norton Scale59 Gosnell Scale58 Waterlow Scale57 Braden Scale56 in the scale/ 1962 1973 1985 1987 subscales Physical condition, mental Nutrition subscale rated 1-3; Based on the Norton Scale Sensory perception, Scoring state, activity, mobility, Continence, mobility, and Subscales include build/weight mobility, activity, Cut-off scores and incontinence moisture, and activity subscales for height, visual assess- nutrition subscales Validity Subscales rated 1-4 rated 1-4. ment of skin in area at rated 1-4. Mental status subscale risk, sex and age, conti- Scores (sum of subscales) rated 1-5. nence, mobility, appetite, Friction and shear range from 5 to 20; Vital signs, skin appearance, medication, and special subscale rated 1-3. lower score indicates diet, 24-h fluid balance, risk factors. higher risk. medication, and Subscale ratings vary by item. Scores (sum of subscales) interventions documented range from 6 to 23; Score of 16 is cut-off to indi- but not scored. Scores (sum of subscales) lower score indicates cate risk. Scores (sum of subscales) range from 0 to .20; higher risk. range from 5 to 20; higher score indicates Sensitivity 5 0%-80% lower score indicates higher risk. Score of 16 is general Specificity 5 31%-94% at a higher risk. cut-off to indicate Score of 16 is cut-off to indi- Score of 16 is cut-off to risk; a score of 18 has cut-off score of 1667 cate pressure ulcer risk. indicate risk. been suggested for patients with darker Sensitivity 5 50%-85%, Sensitivity 5 73%-100%, skin tones.207-209 Specificity 5 73%-83%66 Specificity 5 10% at a Sensitivity 5 83%-100%, cutoff score of 1567 Specificity 5 64%-90% at a cutoff score of 1653,67 Prevention and treatment interventions in which the Etiology physical therapist makes an important contribution in- clude maximizing mobility/activity levels, including Venous insufficiency ulcers result from venous hyperten- transfer training in a manner that eliminates or reduces sion in the superficial and deep venous systems of the friction and shear. Chair-bound individuals should be lower extremities, generally related to one of three instructed in weight-shifting every 15 minutes. If a pa- conditions: venous obstruction, incompetent valves, or a tient or caregiver is unable to transfer effectively without dysfunctional calf muscle pump.69,73-77 The calf muscle creating shear or friction, the use of draw sheets or me- pump is composed of the calf muscles as well as the chanical transfer devices may be indicated. In addition to superficial and deep veins, which are connected by per- implementing mobility interventions, the physical thera- forator veins. The calf muscle pump is the main mecha- pist is also called on to make recommendations for ap- nism by which venous blood is returned from the lower propriate support surfaces.51,60 extremities to the heart. When the calf muscles contract, blood in the deep venous system is pushed toward the VENOUS INSUFFICIENCY ULCERS heart; when the calf muscles relax, blood in the superfi- cial venous system is allowed to flow to the deep veins Epidemiology through the perforator veins. Valves within the veins prevent retrograde flow, or reflux, of the venous blood Frequently and incorrectly called “venous stasis” ulcers, once it has advanced in a cephalic direction.73-75 With venous insufficiency ulcers account for up to 95% of all venous insufficiency the valves that typically prevent lower extremity wounds and can cost up to $40,000 for retrograde flow of blood become incompetent, thus lifetime treatment of recurrent ulcers.69 It is estimated unable to prevent venous reflux. that up to 2.5% of the total U.S. national health care budget is spent treating venous insufficiency ulcers.70 There are several theories that attempt to explain how Chronic venous insufficiency is estimated to affect venous hypertension resulting from incompetent valves between 10% and 35% of the U.S. population.69,71,72 leads to lower extremity ulceration. The fibrin cuff theory Four percent of people older than age 65 years have a hypothesizes that venous hypertension extends to the cap- venous ulcer.72 illary beds, increasing intravascular hydrostatic pressure and allowing fibrin to escape through the capillary wall,

366 CHAPTER 19  Impaired Integumentary Integrity forming a pericapillary fibrin cuff that prevents the usual or ankle leading to impairment of the calf muscle pump; exchange of oxygen, nutrients, and metabolic wastes to deep vein thrombosis (DVT); and congenital abnormali- and from tissues.69,76 The white cell trapping theory states ties of the venous system.77,78 All of these risk factors are that the decreased capillary flow causes leukocytes to re- associated with dysfunctions of either the calf muscles or lease enzymes, free radicals, and lipids that damage the the veins of the calf muscle pump. cell wall, thereby increasing its permeability to larger mol- ecules that leak into the interstitial space.69,76 A third In addition to compression interventions, ambulation theory, the trap theory, suggests that large molecules is often an effective treatment for venous insufficiency by including fibrin leak out of the capillaries and trap increasing venous return from the calf muscle pump. Full substances required for tissue function.69 ankle plantarflexion and dorsiflexion as well as the attainment of a proper heel-to-toe gait pattern maximize There is no consensus regarding which theory most the efficacy of the calf muscle pump.77-79 accurately explains how venous hypertension leads to lower extremity ulceration. Regardless of the specific etiol- General Approaches to Venous ogy, once lower extremity tissue is compromised, it is more Insufficiency Wound Management prone to break down, forming a venous insufficiency ulcer. The cornerstone of treatment for venous insufficiency Venous insufficiency ulcers commonly occur on the ulcers is compression.73,80,81 However, compression is con- lower leg just proximal to the medial malleolus, in what traindicated in the presence of arterial insufficiency.69,76-80 is known as the “gaiter” region (Figure 19-9). Venous Therefore, the first step to treating a venous insufficiency insufficiency ulcers are often chronic, vary in size, have ulcer is to rule out underlying arterial disease. Compres- irregular borders, and typically have heavy drainage.69 The sion is typically achieved through either elasticized or skin surrounding the ulcer may have a ruddy discoloration paste-containing bandage systems. Elasticized bandages known as hemosiderin staining, the result of red blood apply active compression to the extremity whereas paste- cells leaking into the extravascular tissue. Lower leg tissues containing rigid bandage systems enhance the effects of the may take on a woody texture and an inverted champagne calf-muscle pump in facilitating venous return. Occasion- bottle shape, a condition known as lipodermatosclerosis. ally, the limb is treated with an intermittent compression Lipodermatosclerosis is the result of repeated leakage of pump. Regardless of ability to ambulate, patients with fibrin into the lower extremity tissue. venous insufficiency ulcers should be educated in elevating the lower extremities to decrease dependent edema.77 Venous Insufficiency Wound Risk Factors and Wound Prevention Strategies Current evidence regarding the efficacy of physical agents on venous insufficiency ulcers is mixed. However, Risk factors for venous insufficiency ulcers include ad- several clinical practice guidelines recommend consider- vanced age; female sex; family history; smoking; obesity; ation of electrical stimulation,77,79 negative pressure pregnancies; a job requiring long periods of sitting or wound therapy,79 and pulsed electromagnetic field,77 standing; trauma; arthroscopic surgery of the hip, knee, particularly for recalcitrant wounds, while recommenda- tions for ultrasound remains the subject of debate.77,79 Laser and phototherapy are not recommended in the treatment of venous insufficiency ulcers.79 In cases of recalcitrant venous stasis ulcers, surgical interventions may be considered. The most common surgi- cal intervention to address chronic venous insufficiency is subfacial endoscopic perforator surgery, which prevents backflow of venous blood from the deep to the superficial venous system.69,77,79 Other surgical options include super- ficial venous ablation and free flap transfers with micro- vascular anastomoses when severe lipodermatosclerosis is present.79 In addition to these procedures, the use of bilayered artificial skin equivalents in combination with compression therapy has been found to improve venous ulcer healing compared to compression alone.69,79 FIGURE 19-9  Venous insufficiency ulcer. (From Kamal A, Brockel- ARTERIAL WOUNDS hurst JC: Color atlas of geriatric medicine, ed 2, Mosby Year Book, Epidemiology Europe, 1991.) Arterial insufficiency plays a role in as many as 22% of lower extremity ulcers.81 Arterial disease is defined as an ankle/brachial index (ABI) #0.9. Studies estimate that

CHAPTER 19  Impaired Integumentary Integrity 367 17% of the population aged 55 to 74 years has some form of arterial circulatory impairment and that approximately 1% of the population older than age 50 years has arterial insufficiency severe enough to threaten the viability of the lower extremity or warrant surgical revascularization.82 Risk of arterial insufficiency ulceration increases with age: the prevalence of arterial ulceration is 1.5% for people between the ages of 60 and 79 years but increases to 3.5% for people aged 80 to 89 years.83 Often, arterial insufficiency is not treated early in its progression because symptoms do not com- monly present until the disease is in its later stages.84 Etiology FIGURE 19-10  Arterial insufficiency ulcer. (From Black JM: Medical- Arterial insufficiency ulcers result from ischemia due to surgical nursing: clinical management for positive outcomes, ed 8, lack of arterial blood flow supplying the area of the Saunders, Philadelphia, 2008.) wound. The most common cause of arterial insufficiency is arteriosclerosis obliterans (ASO), though trauma and should be controlled such that the hemoglobin A1C level thrombosis can also impair arterial blood flow.85,86 ASO is is less than 7%, indicating acceptable control of diabe- a progressive disease of the aorta and arteries of the lower tes. Hemoglobin A1C is a blood test that demonstrates extremity. Over time, the lumen of the artery is slowly overall blood glucose control over a period of 2 to occluded with plaques, or atheromas, that form between 3 months. Smoking cessation should be encouraged,91-96 the endothelial layer of the artery, known as the intima, and hypertension should be controlled to less than and the smooth muscle layer, known as the media. These 140/90 mmHg or 130/80 mmHg in people with diabetes plaques are mainly composed of macrophages and choles- mellitus or chronic renal insufficiency. LDL cholesterol terol. In addition to the accumulation of plaque, the should be decreased, possibly with the prescription of involved arteries frequently present with fibrosis and calci- statin drugs to less than 70 mg/dL. Hypothyroidism fication, which cause hardening of the artery, or athero- should be treated to prevent the development of arterial sclerosis.87 It is uncommon for a lower extremity ulcer to insufficiency. However, once arterial insufficiency is pres- result from pure arterial etiology. However, arterial insuf- ent, it will not slow the progression of the disease. Ele- ficiency plays a role in the nonhealing status of many vated plasma homocysteine levels can be reduced by wounds with other primary etiologies.88 administering folic acid, vitamin B6, and vitamin B12.90 Patients with arterial insufficiency may complain of In patients with intermittent claudication, there is intermittent claudication, nocturnal leg pain, or leg pain strong evidence supporting the benefit of lower extrem- at rest.80,89 Legs with arterial insufficiency generally lack ity aerobic endurance therapeutic exercise for improving hair 80,86 and present with thin, cool, shiny skin with lower limb peripheral blood flow.88 Therapeutic exercise minimal or no edema.86 Arterial insufficiency ulcers tend may also improve other risk factors for ulcer formation to occur at the lateral foot but may occur in other loca- including high glucose levels and high cholesterol. tions such as the distal toes. As illustrated in Figure 19-10, arterial insufficiency ulcers typically have well-defined General Approaches to Arterial borders with a “punched out” appearance, minimal Wound Management drainage, and a wound base that may range from red granulation tissue to pale, dry necrosis.80,86 The treatment that will lead most directly to healing of arterial insufficiency ulcers is revascularization to restore Arterial Wound Risk Factors arterial blood flow.88 Every patient with a lower extremity and Wound Prevention Strategies ulcer should undergo testing for arterial disease.88 Two noninvasive tests for arterial insufficiency are the ABI and Risk factors for arterial insufficiency and subsequent ulcers include age greater than 50 years, male gender, diabetes mellitus, smoking, hypertension, hyperlipid- emia,82,86,88 obesity and hypothyroidism,86,88 elevated low-density lipoprotein (LDL) cholesterol, and increased plasma homocysteine levels.90 Homocysteine is an amino acid found in the blood. Controlling risk factors can help prevent wound for- mation in patients with arterial insufficiency. Diabetes

368 CHAPTER 19  Impaired Integumentary Integrity the TBI. Not every patient with an abnormal ABI will a normally functioning foot, weight-bearing forces are require revascularization. However, a referral to the vas- distributed across relatively large surface areas, with the cular surgeon is always recommended.88,89 Regardless of majority of the body’s weight being borne on the heel the need or plan for surgical revascularization, lifestyle and metatarsal bones. Less weight is borne on the mid- modifications must be encouraged including smoking ces- foot and hallux, and very little weight is borne on the sation, and improved control of cholesterol and glucose if four smaller toes.102 When biomechanical abnormalities necessary.86,88 Because of the increased risk of infection in exist, the typical distribution of body weight can become ulcers with suboptimal arterial flow and oxygenation, disrupted, with smaller surface areas subjected to larger topical antimicrobial dressings should be considered to forces. manage bioburden.88 Dressing selection for arterial insuf- ficiency ulcers is similar to that of ulcers of any etiology. Diabetic neuropathy tends to affect the long, fine mo- The selected dressing should maintain a moist wound bed tor neurons that innervate the lumbrical muscles of the (except in the case of dry eschar in the absence of ade- foot. Once intrinsic muscle function is impaired, multi- quate arterial supply) and should be cost-effective.88 ple biomechanical changes can occur, including claw Selected physical agents may also facilitate improved heal- foot, hammer toes, and Charcot arthropathy.103 Diabetic ing of arterial insufficiency ulcers. Ultrasound has not neuropathy decreases temperature, pain, and vibration been well studied in arterial insufficiency ulcers. Despite a sensations, leading to a loss of protective sensation of the lack of high-quality studies, electrostimulation and topical foot. The combination of abnormal weight bearing and negative pressure wound therapy appear to be promising absence of sensory feedback can lead to the rapid pro- options worthy of additional research.88 Intermittent gression of an ulcer before it is even detected. Abnormal pneumatic leg compression has been shown to improve weight bearing leads to the development of calluses and distal perfusion and may be beneficial before or after ulcers over bony abnormalities, most commonly the first revascularization.88 Hyperbaric oxygen therapy should be and second metatarsal heads and the hallux.104 considered in patients who are not candidates for surgical Decreased dorsiflexion and decreased motion at the sub- revascularization or for those whose ulcers are not healing talar joint increase pressure on the forefoot, leading to despite vascularization.88 ulceration105; hallux limitus increases pressure under the great toe, which can lead to its ulceration.106 DIABETIC NEUROPATHIC ULCERS Autonomic neuropathy can accompany motor and Epidemiology sensation neuropathy. Autonomic neuropathy causes decreased skin hydration and an inability to inhibit the It is estimated that between 20.9% and 23.1% of adults arteriovenous shunting mechanism, thus increasing over- older than age 60 years have some form of diabetes,97 all blood flow in the diabetic foot.107 However, this and the risk of being diagnosed with diabetes increases blood is shunted away from capillaries of the skin and is with age; moreover, adults older than age 74 years have therefore unable to contribute to local tissue nutri- the highest risk of diabetes.98 Diabetic foot ulcers are one tion.107,108 Finally, older adults with diabetes are com- of the many negative conditions associated with having monly also at risk for atherosclerosis, particularly in diabetes. The risk of diabetic foot ulcers increases with tibial and peroneal arteries, which can further contribute length of disease, and the Centers for Disease Control to arterial insufficiency.109 and Prevention (CDC) reports that 9% of people with diabetes older than age 75 years have a history of dia- Several classification systems exist to provide a com- betic ulceration.99 Other risk factors for development of mon language for describing the risk and extent of dia- a diabetic ulcer include white race, Hispanic ethnicity, betic ulcers. The Wagner Wound Classification System not being married or cohabiting, obesity, use of insulin, (WWCS)110 (Table 19-4) and the University of Texas (UT) and smoking.99 Treatment-based Diabetic Foot Classification System111 (Table 19-5) are the most commonly used. The WWCS, Etiology TABLE 19-4 Wagner Wound Classification System for Diabetic Ulcers110 Diabetic ulcers of the lower extremity develop as a con- sequence of neuropathy, arterial insufficiency, or both.100 Grade Description Risk factors for the development of an ulcer in people with diabetes include callus formation, trauma, neurop- 0 No open lesion but may have deformity or cellulitis athy, peripheral vascular disease, and history of previous 1 Superficial ulcer, partial or full-thickness ulcer or amputation.101 In contrast to the prolonged 2 Ulcer extends to ligament, tendon, joint capsule, or pressure that causes a typical pressure ulcer, diabetic ul- cerations form as a result of repetitive mechanical stress deep fascia without abscess/osteomyelitis on the weight-bearing structures of the insensate foot. In 3 Deep ulcer with abscess, osteomyelitis, or joint sepsis 4 Gangrene localized to forefoot or heel 5 Extensive gangrene

CHAPTER 19  Impaired Integumentary Integrity 369 TA B L E 1 9 - 5 University of Texas Treatment-Based Diabetic Foot Classification System111 and Recommended Prevention and Treatment Interventions at Each Category104 Category Description Examine/Evaluate Footwear for Offloading Surgical Offloading 0 Protective sensation intact Screen annually Recommend slippers with Elective surgery for bunions/other 1 Loss of protective sensation Screen every 6 months firm soles deformities; nail wedge resection; ensure sufficient 2 Loss of protective sensation Screen every 3-6 Wear professionally fitted shoes; blood flow 3 with deformity months extra depth and width footwear with Elective surgery for hammer toes, 4A Loss of protective sensation Screen every 3 months custom total contact bunions, hallux limitus; 4B with deformity and history orthotic (CTCO) Achilles tendon release; nail 5 of pathology See weekly or every wedge resection; ensure 6 other week as Extra depth modified or sufficient blood flow Noninfected, nonischemic needed custom made; wound Elective surgery same as See for wound care as Consider rocker plus CTCO category 1 Acute Charcot arthropathy needed Extra depth modified or Elective surgery same as Diabetic foot infection Urgent revascularization custom made category 1 indicated Rocker plus CTCO Critical ischemia Urgent: if recurrence of ulcer Footwear not appropriate: use imminent, nonsurgical offloading device (total attempts ineffective contact cast, walker, healing sandal, bivalve custom-made Urgent and emergent walking orthosis) See category 1 Aggressive debriding of ulcers See 4A&B if needed Urgent and Emergent Bypass surgery if required Reduction of ulcer bioburden (Adapted from Orsted H, Searles G, Trowell H, et al. Best practice recommendations for the prevention, diagnosis, and treatment of diabetic foot ulcers: update 2006. Wound Care Canada 4(1):57-71, 2006.) which has been in existence longer, describes existing ul- General Approach to Management cerations. In the UT system, the categories are organized of Diabetic Ulcers to provide explicit recommendations for both the preven- tion and treatment of diabetic ulcerations. The UT is more Although all patients with diabetes should be examined and descriptive, with both grades and stages, and has been evaluated for appropriate footwear, those who already have found to be a better predictor of clinical outcome when an ulcer require more aggressive offloading. Offloading is compared to the WWCS with respect to risk of amputa- defined as “any measure to eliminate abnormal pressure tion and prediction of ulcer healing.112 points to promote healing or prevent recurrence of diabetic foot ulcers.”103 Methods of offloading that limit functional Diabetic Ulcer Prevention and Risk mobility and activities of daily living (ADL) generally lead Assessment to noncompliance and less successful outcomes. For this reason, offloading should be achieved while maintaining the Preventing diabetic ulcers requires regular screening and patient’s ability to ambulate, if possible.103 Options for assessment of patients with diabetes for lower extremity offloading diabetic feet include total contact cast (TCC),113 sensory and circulatory impairments. All patients with removable walking boots,113,114 offloading shoes,113,115 heal- diabetes should be periodically examined for decreased ing sandals,116 and ankle–foot orthoses (AFOs).100-104,117,118 protective sensation of the feet using monofilaments. Patients with decreased protective sensation should be Local wound care to diabetic foot ulcers is similar to educated in daily skin inspections and foot care,100,103 and that for ulcers of other etiologies. Necrotic or devitalized examined and evaluated for appropriate footwear.104 Arte- tissue should be debrided once adequate vascular supply rial insufficiency should be assessed using the ABI or has been confirmed, and a dressing should be selected to TBI.89,100 facilitate moist wound healing.100,103,104 Physical agents that should be considered in the treatment of chronic

370 CHAPTER 19  Impaired Integumentary Integrity diabetic foot ulcers include hyperbaric oxygen ther- Review of Systems apy,100,103 electrical stimulation, and negative pressure wound therapy.100 The APTA Guide to Physical Therapist Practice137 identi- fies four areas to be included in the review of systems: the EXAMINATION AND EVALUATION OF integumentary, cardiopulmonary, neuromuscular, and SKIN AND WOUNDS IN OLDER ADULTS musculoskeletal systems. Each of these systems can con- tribute significantly to skin impairments and healing. An Effective skin and wound examination and evaluation initial review of each system helps to focus the specific rely heavily on observation but also include history tak- tests and measures for the physical therapy examination. ing, review of systems, and the selection of appropriate tests and measures. The examination and evaluation The integumentary system is the most obvious com- should look beyond the specific skin impairment to the ponent of a systems review when discussing skin and entire patient because of the complex constellation of wound care. The physical therapist should be aware that factors such as medications and comorbid conditions many patients with skin impairments may initially seek that contribute to skin and wound healing. The fre- physical therapy for other, seemingly unrelated ailments. quency of skin and wound examination and evaluation Intact skin should be observed for any discoloration varies by setting: typically wounds are assessed daily or compared to surrounding skin: areas of darker pigmen- with each dressing change in the acute setting, and tation may indicate an area at risk for pressure ulcers, weekly in long-term care and home care settings; skin whereas lighter areas may indicate scars where previous and wound assessment should be completed more fre- wounds have already healed. Palpation of irregular areas quently if there are any signs of deterioration.41,119 or areas where the patient has complained of pain may reveal increased warmth or a difference in texture. An History area that is indurated or firmer than the surrounding skin may indicate scar tissue, inflammation, or infection. A concise but accurate history must be collected including Areas that are warmer than the surrounding skin may be medical and social history, diet, and medications. These inflamed or infected. Surgical wounds healing by pri- data provide important insights into the patient’s overall mary intention can be gently palpated to identify a heal- health status and risk for integumentary impairments: ing ridge along the incision. A healing ridge is generally diseases or comorbid conditions that increase the risk of palpable by the fifth postoperative day and is a sign of developing a wound or other skin condition, or that might granulation underneath. After 2 to 3 weeks, the healing contribute to delayed healing of a wound or condition ridge softens and is no longer palpable.119,124 that is already present. Medications should be reviewed for any drugs that might delay wound healing, such as Cardiovascular complaints may range from symp- steroids or other immunosuppressants. The patient’s toms of impaired circulation to complaints of impaired nutritional status should be assessed with basic questions endurance that may put a patient at risk for immobility about appetite and dietary restrictions. Lab tests provid- and a subsequent pressure ulcer. Reports of pain may ing prealbumin and albumin levels should be noted. indicate areas that should be examined for signs of tissue damage; complaints of intermittent claudication indicate Albumin is the most highly concentrated protein in patients who are at risk for arterial insufficiency wounds. the blood. Lab tests for albumin measure the amount of Observe for lower extremity edema or rust-colored albumin in the serum (the clear portion of the blood). hemosiderin staining as this may indicate risk for venous Normal ranges for serum albumin vary depending on the insufficiency wounds. laboratory completing the test but are generally 3.4 to 5.4 g/dL. Low values of albumin may indicate decreased The musculoskeletal and neuromuscular systems play absorption of protein but can also herald liver or kidney an integral role in wound prevention and healing. disease and are associated with acute inflammation and Impaired mobility status puts a patient at risk for many shock. High levels of albumin may indicate dehydration. different types of skin conditions and wounds. Muscle Serum albumin has a half-life of approximately 21 days weakness may prevent a patient from repositioning. and therefore may not be a timely indicator of current Contractures cause pressure points on splints and make nutritional status; rather, it is an indicator of nutritional it difficult to adequately clean and dry affected areas of status over the course of several weeks.120-123 the body. Impaired sensation eliminates one of the body’s first warning signs that pressure is building under Prealbumin is another test of serum protein that may a bony prominence. indicate protein-calorie malnutrition. The normal range for prealbumin is 17 to 40 mg/dL. Like albumin, preal- Tests and Measures bumin lab values may appear low in the presence of inflammation. Prealbumin has a half-life of about 2 days If an open area is present, the location should be noted and is therefore a better indicator than albumin of a and it should be measured for greatest length, width, and patient’s current nutritional status.120-122 depth.119,125,126 If any undermining or tunneling is present, this should also be measured and documented

CHAPTER 19  Impaired Integumentary Integrity 371 relative to its location on the face of a clock.119,127 FIGURE 19-11  Semmes-Weinstein monofilament test.  (Courtesy Undermining is a pocket of separation between the superficial or deep fascia and the underlying tissues. of Erica LaPierre, PT, 2009; VNA of CNY, Syracuse, NY. ) Tunneling is a linear tract extending beyond the wound opening.26 Tissue in the base of the wound should be the brachial artery and the ankle. It is noninvasive observed, identified, and documented as a percentage of and approximates central systolic blood pressure.80,130 the total wound surface area. Clinicians may observe ABI examinations compare favorably in diagnosing several types of tissue in the wound base. Granulation lower extremity arteriosclerosis when compared to tissue is red and bulbous scar tissue that may resemble angiography.89,131 the surface of raspberries. Clean, nongranulating tissue may have similar color to granulation tissue but with a In order to take an accurate ABI, the following proce- smoother texture; if striations are present it is likely that dure should be followed.132 Take brachial blood pres- muscle is being observed. Slough and eschar are both sures bilaterally using a Doppler ultrasound to listen necrotic tissue and both may range in color from yellow for the brachial pulse. Inflate the blood pressure cuff 20 or green to gray or black. Slough tissue is moister than to 30 mmHg beyond the point when the brachial pulse eschar and may appear with a slimy or stringy texture. is obliterated. Release the pressure on the blood pressure Eschar is dehydrated and is much firmer than slough; cuff at a rate of 2 to 3 mmHg per second, noting the eschar may have the texture of leather or even wood. pressure when the brachial pulse is once again audible. Document the value for each arm; however, the higher of The wound edges should be observed and noted as the two measurements will be used to calculate the ABI. being either open or closed. A closed wound edge is To measure ankle pressure, place the blood pressure cuff called “epibole” and occurs when the edge of the wound around the ankle approximately 2.5 cm proximal to the rolls over, prematurely halting the epithelialization pro- malleoli. Use the Doppler device to measure the systolic cess. Open wound edges, identified by a narrow, red, flat dorsal pedal and posterior tibial blood pressure in both border of moist tissue, are necessary to allow epitheliali- legs using the same procedure as with the brachial pres- zation to occur from the periphery of the wound toward sure. For each leg, use the higher of the two arterial the center.128 pressures for calculating the ABI. The formula for calcu- lating the ABI is simply the ankle systolic blood pressure Wound drainage should be observed for quantity and divided by the brachial systolic blood pressure. As dis- quality. If there is a thick or purulent texture to the played in Table 19-6, if the ABI results in a value greater drainage, this may be a sign of infection. Drainage fre- than 1.3, the test should be considered invalid because quently has an odor but the odor of the wound should calcification of the arterial walls may be present and not be assessed until after the wound has been cleansed. preventing complete compression of the artery with the If an odor is still present in the wound after cleansing, blood pressure cuff. In the event of an ABI result greater this is another sign of possible infection. Other signs of than 1.3 a TBI should be performed133 (Figure 19-12 and wound infection include increased wound pain, drain- Table 19-6). age, deterioration of tissue in the wound base, and dete- rioration in the wound measurements over time.119,129 The toe/brachial index (TBI), like the ABI, is a com- parison of blood pressure in the arteries of the great toe Testing of neuropathy, or lack of protective sensation, can be reliably and easily completed with the use of a 5.07 (or 10 g) Semmes-Weinstein monofilament.100,103,104 These thin nylon monofilaments are calibrated accord- ing to the force required to cause them to buckle when they are briefly pressed against the skin at a right angle to the skin (Figure 19-11). The thinner the filament, the lower the monofilament number and the less force required to induce buckling. The thinner filaments are, therefore, considered more sensitive. Protective sensa- tion in the foot is considered absent if an individual can- not feel the 5.07 monofilament. Monofilament testing should be performed at several sites on the foot empha- sizing areas exposed to high weight-bearing pressure. Ankle and Toe Brachial Index An ABI should be performed any time a patient has a lower extremity wound in order to rule out arterial involvement in the development of the wound.88 The ABI is simply a comparison of systolic blood pressure in

372 CHAPTER 19  Impaired Integumentary Integrity TA B L E 1 9 - 6 Ankle/Brachial Index Values The same calculation is used for TBI as ABI with the and Implications for Treatment89 substitution of toe pressure instead of ankle pressure. ABI Interpretation Recommendation An alternate method of examining the arterial pressure in the toe is to use photoplethysmography (PPG), which 1.3 or higher Abnormal, may suggest Assess with toe/ uses infrared light instead of ultrasonic waves to measure 1.0-1.2 calcification of arte- brachial index the pressure in the arteries of the toe.134 A transducer is rial walls which are placed on the great toe and systolic pressure is measured therefore unable to Maintenance with a photoplethysmograph (Figure 19-13) instead of a be compressed by compression, Doppler device. Normal values for toe systolic pressure are blood pressure cuff. if needed greater than 50 mmHg; values less than 30 mmHg indicate Inaccurate reading. ischemia and possible risk of amputation.134,135 Normal Compression values for TBI are less well documented than Normal Light compression, for ABI; however, it is thought that TBI of 0.64 or less is associated with arterial disease.134,136 0.8-1.0 Mild arterial disease referral to 0.5-0.8 Mixed venous and vascular surgeon Other diagnostic tests for arterial insufficiency include No compression, segmental leg pressures, which compare blood pressure at ,0.5 arterial disease referral to the thigh, calf, and ankle; pulse volume readings, which vascular surgeon measure arterial stenosis; transcutaneous oximetry, which Arterial insufficiency tests for microvascular insufficiency; magnetic resonance imaging, which can determine the extent of arterial ob- ABI, ankle brachial index struction; and lower extremity arteriography, which is the gold standard for testing arterial disease although it is the and the brachial artery. TBI is recommended when ABI is most invasive of these diagnostic tests.86 When diagnostic greater than 1.3 because the arteries of the toes are not as tests of circulation such as previously mentioned are re- susceptible to calcification. In cases where the great toe quired, the role of the physical therapist is to identify the has been amputated or is otherwise not present, the sec- need for further testing and to refer out to the appropriate ond toe may be used. To measure systolic pressure in the physician to facilitate the tests. toe arteries, a toe-size blood pressure cuff is applied to the toe just distal to the metatarsophalangeal joint. A Physical Therapy Diagnosis Doppler device is used to find the pulse of the toe artery; the blood pressure cuff is then inflated to 20 to 30 mmHg Table 19-7 provides an overview of signs and symptoms beyond the point when the toe pulse is obliterated. The that help differentiate arterial, venous, and diabetic blood pressure cuff pressure is released at a rate of 2 to ulcers. The major contributing cause of the ulcer 3 mmHg per second until the pulse is once again audible. helps determine prognosis and treatment recommenda- tions. The APTA Guide to Physical Therapist Practice137 outlines five practice patterns to offer guidance to physi- cal therapists in the management of integumentary im- pairment. The first pattern describes primary prevention FIGURE 19-12  Ankle/brachial index test: blood pressure cuff FIGURE 19-13  Photoplethysmography.  (Courtesy of Patrick placement and Doppler ultrasound placement to measure systolic Remenicky, PT, CWS, 2009; VNA of CNY, Syracuse, NY. ) pressure through dorsal pedal pulse. (Courtesy of Erica LaPierre, PT, 2009; VNA of CNY, Syracuse, NY. )

CHAPTER 19  Impaired Integumentary Integrity 373 TABLE 19-7 Differential Diagnosis of Lower-Extremity Ulcers Characteristic Typical location Venous Ulcers Arterial Ulcers Diabetic Ulcers “Gaiter” area: medial aspect of lower leg, Lateral foot, distal toes, or at First and second metatarsal heads and proximal to malleolus the site of trauma or hallux; may occur any place on ill-fitting footwear diabetic foot subjected to trauma, pressure, or friction Wound depth Typically shallow; base may be beefy red or May be shallow or deep; and base covered in thin, yellow fibrin film May be deep, undermining/tunneling typically pale pink or grey, may be present; base may be Margins Irregular margins granulation tissue or necrosis may be necrotic Drainage Moderate to heavy Regular, “punched out” Typically regular and round from pressure, callus may be present appearance Little, if any Low to moderate; heavy drainage may suggest infection Surrounding skin Hemosiderin stained, edematous, may have Thin, cool, dry, shiny, hairless Pain reports woody texture with “inverted champagne May be thin and dry as with arterial bottle” shape (lipodermatosclerosis) May report intermittent ulcers claudication, night pain, No consistent pattern: may range from resting pain, pain with May be insensate, paresthesia, burning pain-free to severe pain elevation, cramping and risk reduction for integumentary disorders based on Outcome Measures conditions or limitations that might put a patient’s integumentary integrity in jeopardy. The subsequent It can be challenging to determine if a plan of care is four patterns classify impairments based on the depth of effective in facilitating wound healing. There are many tissue destruction, similar to the NPUAP pressure ulcer factors involved in wound examination and evaluation, staging system. The Guide to Physical Therapist Practice and not every factor will show significant improvement or offers an organizational strategy for physical therapists deterioration with each examination. It is, therefore, help- and assists with selection of appropriate tests and mea- ful to use one of several outcome measures to quantify the sures, interventions, outcomes, and prognoses. sum of the changes that a wound has undergone. There have been numerous proposed outcome measures to track Physical Therapy Prognosis wound healing. The two most common, the Pressure Ulcer Score for Healing (PUSH) tool and the Pressure Sore Prognosis is defined as “the determination of the pre- Status Tool (PSST) will be discussed below. dicted optimal level of improvement in function and the amount of time needed to reach that level and may also The PUSH tool was developed by the NPUAP to pro- include a prediction of levels of improvement that may vide clinicians an easy-to-use and reliable tool to track be reached at various intervals during the course of the healing of stage II to IV pressure ulcers and as an therapy.”137 The length of time anticipated to achieve the alternative to reverse staging of pressure ulcers.138-140 skin and wound care goals varies widely and can be as Although developed for use with pressure ulcers, the little as 2 weeks for prevention of wounds; 16 weeks to PUSH tool has also been used to document progress of treat a wound extending into fascia, muscle, or bone; venous ulcers,141 but not for other types of wounds. and as long as 24 months for scar maturation. Many Three subscales including wound length multiplied by factors will contribute to the prediction of the optimal width, amount of exudate, and tissue type are graded level of improvement and function that can be expected and added for a total score ranging from 0 to 17, with for different skin conditions. As clinicians gain more decreasing scores indicating wound improvement. A experience, they become more comfortable synthesizing PUSH score of 0 indicates that the ulcer has closed. The those factors to make a clinical judgment about expected PUSH tool is not intended to replace a comprehensive outcomes. Some of the factors that contribute to the examination and evaluation, but rather to provide an ad- formation of a prognosis include the availability of ditional method to track healing of pressure ulcers.138,140 resources, compliance with the treatment plan, caregiver competence, chronicity of the condition, cognitive abili- The PSST, also known as the Bates-Jensen Wound ties, comorbidities, degree of impairment, functional Assessment Tool, was also developed to provide a uni- abilities, living environment, nutritional status, and psy- versal method for describing the status of pressure chological and socioeconomic factors.137 ulcers, although it has also been used in research to mea- sure the progress of diabetic, venous insufficiency, and arterial insufficiency ulcers.142,143 The PSST consists of two unrated items, wound location and shape, as well as

374 CHAPTER 19  Impaired Integumentary Integrity 13 items rated 1 to 5. The 13 rated items on the PSST PRESSURE RELIEF include wound diameter, depth, edges, undermining, necrotic tissue type, necrotic tissue amount, exudate Mattresses and Cushions type, exudate amount, skin color surrounding wound, peripheral tissue edema, peripheral tissue induration, The wide variety of support surfaces available to manage granulation tissue, and epithelialization. Scores on the pressure in the wheelchair or bed can make it difficult to PSST range from 13 to 65, with lower scores indicating choose the most effective surface. Ultimately, it is best to wound improvement.144 be aware of the benefits and drawbacks of each classifi- cation of support surface in order to make individualized Interventions for Wound Management choices that will be a good fit for each patient. Support surfaces can be divided into two basic categories: static Wound healing, regardless of age and cause, relies on and dynamic. Static surfaces may include standard hos- several basic principles. Wound bed preparation encom- pital bed mattresses, foam overlays, foam mattress passes all interventions that ready the wound bed to replacements, or overlays containing air, gel, or fluid. progress through the predictable phases of healing, or to Static support surfaces tend to be less expensive than accept more advanced wound care interventions such as dynamic but may not provide the level of pressure man- physical agents. Identifying and treating bacterial burden agement necessary to facilitate pressure ulcer prevention is the recognition of, and intervention for, managing or healing. Dynamic support surfaces include alternating colonization or infection of the wound. Filling dead space air overlays, low air loss mattress replacements, turning requires the thoughtful selection of a wound care product or rotating mattress replacements, and air fluidized sys- to make total contact with the entire interior space of the tems. Dynamic support surfaces may provide a greater wound, including undermining or tunneling. Maintaining degree of pressure management but are more expensive an appropriately moist wound bed requires the selection and may make mobility more difficult for patients, espe- of a suitable dressing to absorb excess drainage or to cially those with impaired postural stability because hydrate a dry wound. Maintaining open wound edges of the increased compliance of the surface.60 Scientific involves the prevention and treatment of epibole to allow literature to date offers little evidence that can guide the the wound to fill with granulation tissue from the bottom selection of one support surface over another; however, up and to epithelialize from the edges into the center. the Cochrane review on the topic concluded that foam Protecting from trauma and bacteria requires appropri- mattress replacements were superior to standard hospi- ate cleansing techniques and the use of carefully selected tal beds.68,148 dressing products to insulate the wound bed until the subsequent scar can resume the skin’s duties of acting as Current clinical practice guidelines recommend that the body’s barrier to the outside world. static support surfaces may be considered for patients with pressure ulcers who can assume different positions If there is no improvement in wound status for 2 to without bearing weight on the ulcer or “bottoming out”; 3 weeks, the plan of care should be reevaluated and patients who are unable to change position or who bot- modifications should be made.145,146 Modifications in tom out may benefit more from a dynamic support sur- wound treatment may include changes to the topical face.68 Bottoming out occurs when less than 1 inch of dressing but should also encompass an evaluation of material exists between the pressure point and the bed nutritional status, efficacy of support surfaces and posi- when felt with the palm of the hand. In order to check tioning schedules, and consideration of adjunctive thera- for bottoming out, the therapist should slide his or her pies, which will be discussed later in this chapter. gloved hand between the patient’s weight bearing area or bony prominence and the surface on which the patient is Evidence-Based Practice Guidelines sitting or lying. For example, to assess wheelchair seat- in Wound Care ing, the physical therapist slides his or her gloved hand between the patient’s ischial tuberosity and the wheel- Numerous systematic reviews and clinical practice guide- chair seat. There should be at least 1 inch of cushioning lines have been developed to help wound care practitio- between the patient’s ischial tuberosity and the seat in ners make informed decisions about best practice order to effectively mitigate the force of pressure.68 options for managing wounds. In wound care, we are fortunate to have a number of well-formulated, evi- Footwear for Pressure Relief dence-grounded clinical practice guidelines presented by experts in the field.72,82,83,92,98,102 The recommendations Specialized footwear is an important intervention in pre- of these groups are based on systematic review and inte- venting foot ulcerations in people with diabetes. All gration of the best available literature reviewed and patients with diabetes should be tested for neuropathy. The summarized by an advisory panel of content experts. presence of neuropathy will help guide footwear choices. These guidelines represent systems-level resources that translate evidence into practice guidelines.147 Total contact casts (TCCs) have been identified by many as the treatment of choice for offloading plantar

CHAPTER 19  Impaired Integumentary Integrity 375 diabetic foot ulcers.101,104,118 TCCs provide effective removed at night when the lower extremities are elevated. pressure redistribution over the plantar aspect of the Graduated compression stockings should be replaced foot while maximizing patient compliance with offload- every 4 to 6 months as they lose their elasticity.69,77,78 ing as the cast cannot be removed.103,118 TCC is typically used only in the absence of ischemia101 and infec- An alternative to compression bandages and gradu- tion,101,103 although there is some evidence suggesting ated compression stockings is intermittent pneumatic TCC can be used in the presence of superficial infection compression (IPC).151 This modality consists of an inflat- or moderate ischemia but not both.101,149 There are also able sleeve placed around the lower extremity and in- disadvantages associated with the use of TCC. The dis- flated to between 30 and 60 mmHg of pressure intermit- advantages include high cost, need for specialized staff, tently. IPC can be used in conjunction with other forms inability to visualize the wound, impairment of mobility of compression or as an alternative to compression ban- and ADL, and general discomfort.101 dages in patients who are unwilling or unable to tolerate compression bandages well because of the discomfort One alternative to TCC is a removable walking boot. that may accompany this intervention.76,77,79 A typical A walking boot is relatively inexpensive, easily applied IPC intervention consists of application of 45 mmHg without specialized training, and allows for easy removal at the foot, graduating to 30 mmHg at the thigh. The for wound examination and treatment.101,103,104,118 Half device inflates for 0.5 second, maintains peak pressure shoes, wedge shoes, and healing sandals also mitigate for 6 seconds, and deflates for 12 seconds. Treatment pressure on the forefoot101,118 and provide ease of appli- lasts for 1 hour 5 days per week for up to 6 months.152 cation and removal similar to walking boots although TCC remains the most effective means of offloading WOUND DRESSINGS plantar diabetic ulcers. However, wedge shoes are diffi- cult to walk in and may cause pain or decreased postural With thousands of dressing products on the market in stability.118 Compliance is the most important factor in ever-increasing classifications, it can be challenging to offloading regardless of the method used to achieve the select an appropriate topical treatment to facilitate offloading. If the patient is unwilling or unable to par- wound healing. The choice of wound dressing product ticipate fully in offloading interventions, ulcer healing should be carefully made to provide a wound environ- will be delayed.103 ment that maximizes healing potential. There are several key factors that can guide the clinician in selecting the COMPRESSION THERAPY best dressing or combination of dressing products to aid in wound healing: level of exudates, presence or absence Compression therapy is the cornerstone of treatment for of nonviable tissue, presence or absence of infection, venous insufficiency ulcers. However, compression is con- amount of dead space to be filled, desired wear time, traindicated in the presence of arterial insufficiency.69,76-80 ease of application, pain with dressing changes, and Compression therapy requires 30 to 40 mmHg of pres- cost considerations.68,79,88,100,153,154 These factors, syn- sure to counteract the tissue capillary pressure.69,76,77 thesized using clinical judgment, guide the selection of A variety of products are available to provide the neces- dressings regardless of wound etiology.68,79,88,100 Table sary level of compression. These products include short- 19-8 provides the basic classifications of dressing prod- stretch bandages and paste-containing bandages as well as ucts as well as important characteristics to guide in three- and four-layer bandage systems. Short-stretch and dressing selection. paste-containing bandage systems tend to lose elasticity and are not effective in nonambulatory or minimally am- DEBRIDEMENT bulatory patients. In these cases, the increased active compression of multilayered bandage systems is a more Debridement is the removal of dead or devitalized tissue effective option.77 Different bandage systems vary widely from the wound bed and is an essential step in preparing in cost and ease of application. However, the current the wound to progress through the healing pro- literature states that there is no evidence to support cess.68,77-79,88,100,103,104 Debridement may be accomplished recommending one type of compression bandage over using autolytic, mechanical, and sharp strategies. another.150 What is known is that multilayered systems are more effective than single-layered systems, and high Autolytic compression is more effective than low compression in healing venous insufficiency ulcers.150 Continual and Autolytic debridement employs the use of an occlusive long-term management of venous insufficiency is vital to dressing to trap wound exudate, thereby hydrating prevent future ulcerations. The most common method of necrotic tissue and keeping in endogenous proteolytic providing long-term control of venous insufficiency is the and collagenase enzymes secreted by white blood cells to use of graduated compression stockings. Graduated com- liquefy nonviable tissue. Autolytic debridement is selec- pression stockings provide the needed 30 to 40 mmHg of tive; that is, it will not destroy healthy wound tissue; compression and should be worn during the day and it will only facilitate autolytic debridement of necrotic

376 CHAPTER 19  Impaired Integumentary Integrity TABLE 19-8 Classes of Advanced Wound Care Dressings129,153,154,210-216 Dressing Classification Description Advantages Disadvantages Indications Contraindications Transparent film Permeable to water vapor No absorbency, diffi- IV sites; second- Highly exudating Hydrocolloid Polyurethane sheet or polymer film, coated and gas; water proof; cult to apply ary dressing wounds, infection Hydrogel on one side with allows wound over other adhesive; available as visualization Impermeable to gas wound Ischemia; infection; Collagen/ a sheet and water vapor; products vasculitis Biologics No secondary may cause Minimally Polyurethane foam outer dressing required; periwound exudating Ischemic ulcers Calcium layer, hydrocolloid promotes autolytic maceration with wounds; alginate carboxymethylcellu- debridement increased sloughy Religious/ethical lose/pectin middle drainage; odor wounds beliefs may limit Hydrofiber layer with adhesive Cooling/soothing; may be use in certain inner layer; available facilitates autolytic confused with Dry, sloughy populations Foam as sheets in various debridement; absorbs infection wounds with Antimicrobials thicknesses and minimal exudate minimal Dry wounds, diabetic shapes, specific for More frequent exudate foot ulcers different body areas Encourage deposition of changes; may (heel, sacrum, etc.) new tissue, bind allow prolifera- Chronic wounds Dry wounds excess matrix tion of gram- Hydrophilic polymer; metalloproteases, negative Moderately Dry wounds available in amorphous absorb drainage bacteria exudating sheets or in gel form wounds, after Choose antimicrobial Absorbent, gelling May require debridement if product classifica- Bovine, avian, or porcine action allows frequent hemostasis tion appropriate collagen combined autolytic dressing required to wound with oxidized, debridement, changes characteristics regenerated hemostatic Moderate to cellulose; available in Requires tape or highly sheet, gel, or powder High absorbency, gelling secondary exudating form action allows dressing, odor wounds, autolytic debridement, may be wounds with Kelp derivative strong fibers are ideal confused with dead space calcium alginate for packing dead infection, polysaccharide forms space prolonged wear Highly exudating gel when in contact may increase wounds with exudates; High absorbency, long infection available in fiber wear time, thermal Infected wounds or nonwoven sheets insulation, Requires tape or or ropes permeable to secondary gas and water dressing Carboxymethylcellulose gelling agent; Ionic silver effective Obscures view of available in sheets or against MRSA, VRE, wound ropes reduces inflammation, time release for Increased cost Porous polyurethane foam increased wear time with semipermeable outer layer; available in sheets or rolls Silver- or iodine- impregnated dressings; available in most of the above classifications MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococci.

CHAPTER 19  Impaired Integumentary Integrity 377 tissue. However, it may cause maceration to the skin sur- cases, includes nonhuman trials. However, it does repre- rounding the wound if the skin is not properly protected. sent the best available evidence to guide the clinician in Autolytic debridement is one of the slowest methods of choosing a wound-cleansing method. debridement and is not appropriate when fast removal of necrotic tissue is important. Autolytic debridement Conservative Sharp Debridement may not be effective in frail or immunocompromised patients who lack the ability to produce the endogenous Conservative sharp debridement refers to the use of scis- enzymes needed to break down necrotic tissue. sors, scalpels and forceps to remove necrotic tissue from the wound base to “just above the level of viable tissue Enzymatic margins”166 and should only be performed by a trained clinician. Sharp debridement can also be combined with Enzymatic debridement also uses collagenase enzymes to enzymatic or autolytic debridement in a technique known selectively liquefy necrotic tissue. However, in the case of as “cross-hatching.” Cross-hatching removes eschar by enzymatic debridement, these exogenous enzymes are scoring the surface of the eschar in a criss-cross pattern synthetic and are applied to the wound in the form of with a scalpel in order to increase its surface area. The prescription ointments. Papain urea was a popular pro- eschar is then covered with an occlusive dressing or an teolytic enzymatic debriding ointment but lost FDA enzymatic debridement ointment. Conservative sharp approval because of lack of high-quality research to debridement is contraindicated in cases of arterial insuf- verify its efficacy.155 Collagenase ointments have been ficiency,68,88,166 malignant wounds, and patients with shown to remove necrotic wound tissue faster than clotting disorders. Use of anticoagulant therapy is a rela- placebo in a population of older adults.156 tive contraindication to conservative sharp debride- ment.166 More aggressive sharp debridement “up to and Mechanical including the viable tissue margins”166 can be completed by a surgeon under anesthesia. Mechanical debridement uses deliberate force to nonse- lectively remove necrotic tissue from the wound bed. One SURGICAL INTERVENTIONS of the oldest and most primitive methods of mechanical FOR WOUND CLOSURE debridement is the use of a wet to dry dressing. Wet to dry dressings are painful and nonselective. When the Occasionally surgical intervention is required to close a dressing is removed it brings with it both viable and non- wound that is recalcitrant to healing such as debrided viable tissue, causing inflammation and increasing the osteomyelitis or when rapid wound closure is desired.68 risk of infection. Other methods of mechanical debride- Physical therapists should be aware of the commonly ment use the force of water on the wound bed to loosen used options described in this section. and remove necrotic tissue. Whirlpool is one of the better known means of mechanical debridement, using pro- Skin grafts typically use the removal of a partial pelled water to loosen and remove necrotic tissue, typi- thickness of skin from one area on the body in order cally from the lower extremity by submerging it into a to be transplanted to another. This is known as whirlpool tank with a mechanical agitation component. an autograft. The donor skin is often “meshed,” or Unfortunately, if multiple wounds on the same limb are perforated with many small incisions, which allows it submerged at the same time the risk of cross contamina- to cover a larger surface area on the recipient site. tion from one wound to another increases. Whirlpool Local wound care is required at both the donor and treatment is time consuming and the tanks are difficult to recipient sites and negative pressure wound therapy disinfect in between patients. and hyperbaric oxygen are common adjuvant therapies after a grafting procedure. Although the physical ther- In the past few years, pulsed lavage has replaced apist does not typically treat the graft site itself, physi- whirlpool as an effective, sanitary, and convenient means cal therapy may be called on to provide wound care, of using the force of water to remove devitalized tissue including dressing changes to the donor site from from the wound bed. Pulsed lavage uses a disposable which the graft was obtained. hand piece to irrigate a wound with saline at pressures between 4 and 15 psi. This range of water pressure has A second form of grafting is an allograft, where the been determined to be forceful enough to remove nonvi- donor skin is derived from cadaver, live donor, or cul- able tissue and metabolic waste without causing damage tured sources. In the case of allograft, the donor skin to the healthy tissue in the wound bed.157-165 The saline acts as a temporary biologic dressing and is eventually propelled into the wound base is contained by the tip of removed when the recipient site has improved to the the hand piece and is then contained, along with any extent that more conventional topical treatments will be loosened necrotic tissue, with the use of a suction effective. machine. The evidence to support the specific range of pressures used to irrigate wounds is dated and, in some The muscle flap is a less common option in older adults68 because of the inherent risk-to-benefit ratio of elective surgery. A free flap involves the harvest of a

378 CHAPTER 19  Impaired Integumentary Integrity full-thickness section of tissue including muscle and vas- PHYSICAL AGENTS cular supply that is then placed at the recipient site with microsurgery to connect vascular anastomoses. Free flap When a wound fails to heal in a predictable timeline the transfers are used to treat chronic venous insufficiency physical therapist should consider the use of a modality ulcers when significant lipodermatosclerosis is present.79 to augment wound healing. Evidence favoring the use of Pedicle transfers harvest the donor tissue from an adja- selected modalities is mounting while others have failed cent site, keeping the vascular supply intact and rotating thus far to demonstrate effectiveness as an adjuvant to the flap onto the recipient site. In cases of muscle flaps, the wound plan of care. Table 19-9 provides a summary the physical therapist may be most intimately involved in of the key evidence supporting the use of physical agents assisting with selection of the appropriate support sur- for wound care. face, positioning schedule, and mobility training to fa- cilitate healing of the flap site. Ultrasound Choosing to Debride Ultrasound is one of the most commonly used physical agents in physical therapy and typically consists of the The primary justification for debridement is removal of application of ultrasonic energy in the 1 to 3 MHz range devitalized tissue to stimulate wound healing. In arterial to produce both thermal and nonthermal effects on tis- insufficiency ulcers with dry gangrene or eschar, debride- sue. Based on cellular-level studies,167 researchers have ment should only be attempted if arterial blood flow is theorized that pulsed (nonthermal) ultrasound applied sufficient to facilitate healing.88 to the wound bed stimulates mast cell release of hista- mine, encouraging the migration of monocytes and neu- Even if wound healing is unlikely, debridement of trophils to the wound base. As discussed earlier, neutro- necrotic tissue may be justified if it has a substantive phils contribute to the early phagocytosis of tissue debris impact on odor or the patient’s perception of body and bacteria; monocytes become macrophages, which image. This is often the case in the patient in the final carry out a role similar to neutrophils later in the wound stages of a terminal illness in which a wound is present. healing process. Others have hypothesized that pulsed The individual’s specific goals must guide this decision. ultrasound stimulates increased production of type I col- Debridement can be painful and anxiety producing. If lagen by the fibroblasts, which leads to greater tensile there is little likelihood that wound healing will be strength in the healed wound. The thermal effects of achieved or health status improved, then the decision to continuous ultrasound applied to the wound base have debride should be consistent with the patient’s personal been theorized to increase local circulation. Although goals and preferences. TA B L E 1 9 - 9 Summary of Physical Therapy Modalities for Wound Healing Modality Treatment Goal Physiological Level of Evidence *Based on Oxford Criteria217 Effect of Acute Arterial Venous Pressure Diabetic Modality High-frequency Augment wound healing Accelerates or reactivates none none 1a2168 none none ultrasound none 1b174 4175 none 1b171 Debride wound bed normal wound healing Low-frequency Removes bioburden through none none 4204 4204 4204 ultrasound Augment wound healing, increase protective cavitation and none 2a88 2a79 1b187-189 1b191 Monochromatic sensation infrared microstreaming none 2a88 none none 1a200 energy Augment wound healing, Increases microcirculation by 1b203 2a88 2a79 2a68 2a100 decrease infection Electrical releasing nitric oxide, a stimulation Augment wound healing, decrease infection potent vasodilator Hyperbaric Stimulates endogenous oxygen Augment wound healing bioelectrical activity, Negative-pressure wound bactericidal therapy Increases tissue oxygenation, bactericidal Increases wound granulation, decreases bacteria and edema Note: 1a2, Based on findings of a systematic review of randomized controlled trials, with worrisome heterogeneity; 1b, based on findings from individual randomized controlled trials with narrow confidence interval; 2a, based on conclusions of a systematic review, with homogeneity, of cohort studies; 3b, based on findings from individual case-control studies; 4, based on findings from case-series or poor quality cohort and case-control studies.

CHAPTER 19  Impaired Integumentary Integrity 379 these physiological changes have been observed in Monochromatic Infrared Energy cellular-level research,167 they have not been clearly rep- licated in humans with pathology. There is little clinical Monochromatic infrared energy (MIRE) uses light-emit- evidence to support the use of ultrasound in the 1 to ting diodes to deliver near-infrared energy at 890 nm to the 3 Mhz range to promote wound healing, and what evi- skin and wound base. MIRE is suggested to heal chronic dence does exist is of poor quality.79,168,169 wounds by increasing the microcirculation under the treat- ment area through promoting the release of nitrous oxide, In recent studies, ultrasound of different frequencies which causes vasodilation.176 In 1994, the Food and Drug has been used for its imaging capacity rather than its Administration approved the use of MIRE for increasing therapeutic potential. Ultrasound in the 15 MHz range, circulation and decreasing pain, paving the way to consider known as high-frequency ultrasound, has been used to MIRE as a tool to increased circulation in a wound. The obtain high-resolution images that may aid in the earlier suggested treatment protocol is 20 to 30 minutes 1 to detection of pressure ulcers once a patient has been 2 times per day 3 to 7 times per week.177,178 MIRE is con- screened and determined to be at risk.170 However, traindicated for use over a malignant lesion, active malig- high-frequency ultrasound has no known role in the nancy, during pregnancy, or with patients who may be physiological stimulation of tissue healing. pregnant.178 Very little evidence exists to support the use of MIRE in healing chronic wounds,179 and though it was On the opposite end of the frequency spectrum, low- initially thought that MIRE could reverse diabetic periph- frequency (LF) ultrasound in the range of 40 kHz has eral neuropathy, the evidence to the contrary is mounting been increasingly found to be useful in wound debride- and convincing.180,181 ment via the theorized mechanisms of cavitation and microstreaming.171-175 Cavitation refers to the formation Electrical Stimulation and vibration of micron-sized bubbles in the coupling medium and fluids in treated tissues. As these bubbles Electrical stimulation is thought to augment wound heal- form and condense, they compress and cause changes at ing through the use of electrical currents delivered either the cellular level in the wound tissue. Microstreaming is directly to, or through, the wound base via placement of the movement of fluids along acoustical boundaries electrodes in the wound or on the periwound tissue. In because of the pressure wave created by the ultrasound. theory, electrical stimulation enhances or regenerates the Although a recent addition to the world of wound- “current of injury” that naturally assists in wound heal- healing modalities, low-frequency ultrasound is within ing. Injured skin relies on a slight electrical current, the scope of the physical therapy practice and units are known as the current of injury, to enhance wound heal- currently being developed. ing.182-184 The skin is naturally electronegative in relation to its surroundings and deeper tissues because sweat con- LF ultrasound uses an atomized saline solution to de- tains NaCl, which accumulates on the skin surface. liver ultrasonic energy to the wound base, facilitating Sodium pumps on the surface of the skin transport Na1 wound debridement and promoting increased granula- ions to the deeper layers of the skin, leaving a greater tion; this modality has been found to be an effective ad- concentration of Cl2 ions on the skin’s surface. The elec- juvant to standard care in chronic ulcers of various eti- tronegative charge is thought to assist in the skin’s natural ologies.171-175 In a randomized controlled trial of patients defense against infection and the elements because patho- with chronic diabetic foot wounds, Ennis et al171 found gens are less likely to proliferate in the presence of a nega- that patients who received LF ultrasound treatments for tive charge. A current is naturally formed when the skin is 4 minutes three times per week for 4 weeks healed faster broken due to the electronegative nature of the skin sur- than the control group that received sham treatments. In face and the electropositive deeper tissues; this is known a second study, Ennis et al172 concluded that patients with as the “current of injury.” The electropositive deeper tis- lower-extremity wounds of various etiologies healed sues attract neutrophils, macrophages, fibroblasts and more quickly, with fewer hospitalizations and surgical epithelial cells, which all have negative charges. A moist interventions when treated with LF ultrasound when wound base is necessary to perpetuate the current of compared to historic controls. Kavros et al174 found that injury, allowing it to speed the healing process by attract- a greater proportion of both chronic lower-extremity ul- ing proliferative cells to the wound base. When the wound cers and foot ulcers associated with critical limb ischemia is allowed to dry out or desiccate, the current is halted. reached at least a 50% reduction in size when treated three times per week for an average of 5 minutes with LF Electrical stimulation has been recommended for ultrasound compared to a control group that received the treatment of chronic venous,79 arterial insufficiency standard treatment alone. This study was expanded upon ulcers,88 diabetic ulcers,100 and stage III and IV pressure in 2008175 and patients with chronic lower extremity ulcers.68 However, current guidelines are unable to con- wounds resulting from neuropathy, arterial or venous clude which currents or voltages are most beneficial to insufficiency, or multiple factors healed significantly more different ulcers. Constant low-intensity direct current often when treated three times per week with LF ultra- has been shown to hasten wound healing in pressure, sound compared to matched controls who received stan- dard care.

380 CHAPTER 19  Impaired Integumentary Integrity ischemic, and ulcers of unspecified etiologies with a pro- Hyperbaric Oxygen Therapy posed treatment protocol of continuous low-intensity direct current applied to the wound for intensities of Hyperbaric oxygen therapy (HBOT) has been recom- between 200 and 800 µA for at least 1 hour per day 5 mended in the treatment of diabetic100,103,193,194 and arte- days per week.185,186 Many treatment protocols start rial insufficiency88 ulcers. Research does not support with the negative electrode in the wound base for 3 days hyperbaric oxygen for pressure ulcers.68 Hyperbaric and then the polarity is switched. Other protocols call oxygen compared to standard treatment has been shown for switching the polarity every 3 days throughout the to facilitate a greater decrease in wound size, greater rate course of treatment. of complete ulcer closure, and reduced rate of amputa- tion of the ulcerated limb.195 Although it can be Kloth and Feedar187 used high-voltage, monophasic provided at home, the typical HBOT treatment takes pulsed current in the treatment of “stage IV decubitus place at a hospital or outpatient clinic and lasts 90 to ulcers” involving a 45-minute treatment 5 days per week 120 minutes on a daily basis; in cases of infection, twice- at 105 Hz with an interphase interval of 50 µs and a daily treatment may be ordered. Treatment takes place submotor threshold voltage. With this protocol, treat- in a hyperbaric chamber, with the patient breathing ment was initiated with the positive electrode placed in 100% oxygen at pressures between 2 and 25 atmo- the wound base until a healing plateau was reached; then spheres. The increased pressure in the chamber drives the negative electrode was used to treat the wound. Once oxygen into the blood plasma (because hemoglobin in a healing plateau was reached with the negative elec- the red blood cells is nearly saturated with oxygen at trode, the polarity was alternated on a daily basis. In all normal atmospheric pressures), dramatically increasing cases, the dispersive electrode was placed 15 cm cepha- the partial pressures of oxygen in tissues throughout the lad.187 In a second study of monophasic pulsed current, body. The increased oxygen levels at the wound site are Feedar et al.188 proposed a treatment protocol using thought to increase the oxygen gradient between the monophasic pulsed current applied directly to the wound wound dead space and the periwound.196 The increased base at a frequency of 128 pps and an amplitude of oxygen gradient increases fibroblast division197 and stim- 35 mA for a 30-minute treatment twice daily starting ulates wound healing.103 The increased oxygenation of with the negative electrode in the wound base and alter- tissues during HBOT also increases the ability of leuko- nating to the positive electrode every 3 days. The disper- cytes to combat bacteria and increases angiogene- sive electrode was placed 30.5 cm away from the wound. sis.193,198,199 Hyperbaric oxygen therapy has been found Once the wound was determined to be the depth of a to decrease the risk of major amputation when used to partial thickness wound (this was termed a “stage II” treat diabetic ulcers200 and may increase the 1-year rate wound in the original paper, which was written prior to of healing.194 The Underseas and Hyperbaric Medicine the current philosophy to avoid reverse-staging of Society, which regulates the diagnoses and applications wounds), the frequency was changed to 64 pps and the for which HBO is reimbursable, has approved HBOT as polarity was alternated every day. This protocol was a tool to enhance healing in selected problem wounds, found to be effective with stage II through IV pressure including diabetic foot wounds, compromised amputa- ulcers, vascular insufficiency ulcers, and traumatic or tion sites, nonhealing traumatic wounds, and vascular surgical wounds.188 insufficiency ulcers. HBOT is also approved for [refrac- tory] osteomyelitis, skin grafts and flaps, and thermal A recent double-blind randomized controlled trial burns.201 HBO is not used in every case in which it (RCT)189 found that direct current treatment of pressure is indicated because it is not always readily available, ulcers in a group of older patients and patients with spi- requires lengthy treatments, and presents an added cost nal cord injury increased the initial rate of healing but did to the delivery of care. However, it should be considered not result in a statistically significant improvement in prior to amputation in chronic nonhealing wounds that overall healing. A second RCT190 found that high-voltage lack sufficient tissue oxygenation. electrical stimulation led to higher rates of healing on subjects with venous wounds; the subjects themselves Negative-Pressure Wound Therapy were described to have symptoms of chronic venous insufficiency although no specificity was provided about The use of negative-pressure wound therapy (NPWT) is the chronicity of the actual wounds. High-voltage current suggested by the Wound Healing Society for the treat- was also found to produce a higher rate of healing when ment of stage III and IV chronic pressure ulcers68 and used to treat diabetic foot ulcers.191 nonhealing diabetic ulcers100 as well as before or after flap or graft surgery.79 However, the most recent A lesser known electrotherapeutic modality is electro- Cochrane review of the topic202 concluded that there is magnetic therapy, which uses an electromagnetic field to no evidence to suggest that NPWT is more effective in promote wound healing in contrast to the directly healing chronic ulcers than comparators. Many studies applied current that results from electric stimulation. on the effects of NPWT on chronic wounds have been There is very little evidence to support the use of electro- magnetic therapy, and what exists is unable to reach a conclusion on its efficacy or benefit.192

CHAPTER 19  Impaired Integumentary Integrity 381 small and not well-randomized and are therefore suscep- electrical stimulation, and it has been proven effective in tible to bias; other studies did not separate acute and many types of chronic wounds, whereas low-frequency chronic wounds. Only seven studies met the rigorous ultrasound equipment might not be as readily available. criteria to be included in the Cochrane meta-analysis and HBO may be similarly difficult to access, but may repre- of these, only one demonstrated a statistically significant sent an alternative to amputation in chronic diabetic advantage in the use of NPWT for the treatment of ulcers. Physical therapists must consider the resources chronic wounds. The main outcome reported in NPWT available and the potential risks and benefits to the literature was reduction in wound volume; the Cochrane wound care patient when deciding which physical agents authors point out that a reduction in time to complete to use and when to use them. closure would be a more clinically meaningful outcome. Despite the relative lack of evidence to support the use SUMMARY of NPWT in chronic wounds, one study by Armstrong and Levery203 demonstrated that NPWT led to more The integumentary system undergoes multiple changes patients healing and with a shorter time to closure in a with age but is more profoundly affected by the multiple surgical wound after a partial foot amputation related to comorbid conditions and systemic medications that diabetic complications. occur with increasing frequency in advanced age. Once acquired, wounds undergo the same fundamental cas- NPWT involves the application of subatmospheric cade of reactions and events to progress to closure in pressure to the wound base, usually in the range of 50 to older adults but there are more factors that can slow the 175 mmHg 24 hours a day with several dressing changes process of wound healing in the older populations. The per week. Negative pressure is applied to the wound by physical therapist is an essential member of the wound a portable suction device connected to some form of care team in any setting and can employ his or her wound dressing via tubing. Different manufacturers knowledge of therapeutic exercise, mobility rehabilita- suggest different dressings ranging from gauze to polyvi- tion, and environmental adaptations. The management nyl alcohol foam. NPWT is believed to increase cutane- of chronic wounds should often include the thoughtful ous perfusion and the formation of granulation tissue application of physical agents to augment and speed the while decreasing bacterial load, wound drainage, and healing process. As the demographics of the United edema. Caution should be taken when using NPWT on States shift toward a greater population of older adults, a patient with active bleeding or who is on anticoagulant the absolute number of older adults with impaired in- therapy.179,204,205 tegumentary integrity will also likely increase; physical therapists must be prepared to meet the challenge of col- Choosing among the Various laborating with other health care workers to facilitate Physical Agents wound healing in older adults. Although many physical agents exist for the treatment of REFERENCES wounds, it can be daunting to determine which is the most appropriate and when to use it. Typically, physical To enhance this text and add value for the reader, all agents are considered after the wound has failed to references are included on the companion Evolve site improve or heal with appropriate dressing, nutrition, or that accompanies this text book. The reader can view the other interventions such as offloading, or compression. reference source and access it online whenever possible. NPWT is the one physical agent that is more commonly There are a total of 217 cited references and other gen- used in acute surgical wounds, including grafts and flaps. eral references for this chapter. Most facilities have the necessary equipment to provide

20C H A P T E R Management of Urinary Incontinence in Women and Men Diane Borello-France, PT, PhD INTRODUCTION of routine care, including costs of protective undergar- ments and laundry. In a study of 528 racially diverse, Urinary incontinence (UI), a common health condition community-dwelling women with weekly UI, 69% among older adults, is defined as the complaint of any reported incontinence-related costs averaging more than involuntary leakage of urine.1 Although UI affects both $250 per year (2005 U.S. dollars).13 genders, women have a greater risk of developing this condition. In a recent epidemiological study of a racially Currently, there are many treatment options for per- and ethnically diverse cohort of midlife women, preva- sons with UI, including pharmacotherapy, surgery, pelvic lence of UI that occurred at least monthly was 46.7%; floor muscle (PFM) exercise, and other behavioral inter- and the prevalence of more frequent UI (occurring sev- ventions. In older adults, mental and physical status, eral days per week or more) was 15.3%.2 Although comorbidity, medications, and environment often com- prevalence of “any UI” does not increase substantially plicate the etiology of UI.14 Thus, the physical therapy beyond the 5th decade in women, the prevalence of se- management of older individuals with UI may not be vere UI (daily or a few times/week) does increase from straightforward. The physical therapist will need to care- 24.9% (5th decade) to 38.9% (801 year-olds).3 In men, fully reflect on how these contributing factors affect UI prevalence estimates are substantially lower, reaching the patient’s prognosis and the efficacy and feasibility of 5% and 34% for younger and older men, respectively.4-6 interventions under consideration. The International Continence Society has defined To provide a foundation for clinical decision making, three types of UI: stress UI, urge UI, and mixed UI.1 this chapter reviews the (1) anatomy and physiology of Stress UI is the involuntary leakage of urine that occurs normal continence mechanisms; (2) pathophysiology on effort or exertion, or on sneezing or coughing. Invol- of UI, and risk factors for developing UI; (3) introduces untary leakage of urine accompanied by or immediately UI-specific tools to determine patient outcomes including preceded by urgency (a sudden, strong desire to pass UI symptoms, symptom-related distress, quality of life, urine, which is difficult to defer) defines urge UI. Finally, and sexual function; (4) summarizes the scientific evi- mixed UI is the involuntary loss of urine associated with dence for conservative intervention options for UI (PFM urgency and also with exertion, effort, sneezing, and exercise, biofeedback, electrical stimulation, bladder coughing.1 training, and lifestyle modification); and (5) describes pharmacologic and surgical interventions for UI. Urinary incontinence can seriously affect physical function, psychological well-being, and quality of life. In CONTINENCE MECHANISM older adults, UI has been associated with depressive symptoms, poor life satisfaction, social isolation, sleep Continence depends on the neural coordination of activ- disturbances, increased risks of falls, and a twofold ity between the bladder, urethra, and PFMs. As the blad- increased risk of institutionalization.7-11 Urinary inconti- der begins to fill with urine, bladder pressure is low, and nence also poses a significant economic burden to the the detrusor (bladder) muscle is relaxed.14 As more urine individual and society. In the United States in 2003, the is stored, bladder outlet resistance must increase to estimated annual economic cost of UI was $12.0 billion, maintain continence. For this to occur, bladder afferents with 75% of the cost focused on community-dwelling send information regarding bladder fullness to the dorsal older adults.12 Individuals themselves incur the burden 382 Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc.

CHAPTER 20  Management of Urinary Incontinence in Women and Men 383 horn of the spinal cord. This information is relayed onto interventions for UI are primarily aimed toward improving spinal interneurons that activate somatic pudendal and PFM function. sympathetic hypogastric efferents. Somatic pudendal efferent activation causes contraction of the striated The PFMs include the perineal membrane and levator urethral sphincter and increased pelvic diaphragm ani muscles.17,18 The perineal membrane is the superficial muscle tone. Coincidentally, activation of sympathetic layer of the PFMs and includes the ischiocavernosus, hypogastric efferents inhibits detrusor contractions and bulbospongiosus, and superficial transverse perineal promotes urethral smooth muscle contraction.15,16 Infor- muscles. The levator ani is the deep layer of PFM and mation from bladder stretch receptors is also sent to the includes two basic regions (Figure 20-1). The first and pontine continence center, the periaqueductal gray (PAG) most posterior region, the iliococcygeus and coccygeus matter, and the right anterior cingulate cortex. These muscles, originates from a fibrous band on the pelvic areas promote continence by increasing sympathetic wall called the arcus tendineus levator ani. Together, efferent activity, bladder compliance, and external ure- they form a relatively flat, horizontal shelf spanning thral sphincter tone; inhibiting parasympathetic activity from the pelvic sidewalls on which the pelvic organs (activated during voiding); and facilitating pudendal rest.17,18 The second region of the levator ani muscle motoneurons.16 includes the pubococcygeus muscle. It originates from the pubic bone on either side and forms a sling around Once the individual determines an appropriate time and behind the rectum. It is further delineated into the and place to void, afferent signals from the bladder are puborectalis muscle, the portion of the pubococcygeus sent to the PAG matter. The PAG matter coordinates muscle that passes beside the vagina (in women) and voiding by activating the pontine micturition center attaches to the lateral vaginal walls.17,18 It has been (PMC). The PMC activates parasympathetic pelvic suggested that both layers of muscle function as a unit efferents to the detrusor, causing the bladder to contract. during a PFM contraction.19 Coincidentally, sympathetic and somatic efferents to the urethra are inhibited allowing urethral relaxation and The levator ani muscles are tonically active, providing urine flow.16 constant support to the pelvic organs.20 In women, they narrow the urogenital hiatus and draw the urethra, Continence also depends on the integrity of anatomic vagina, and rectum toward the pubic bone. In this situa- structures that support the pelvic organs and affect urethral tion, the supporting connective tissues experience mini- pressure, including the pelvic ligaments (urethral, cardinal, mal tension. If muscular support is lost, connective tis- and uterosacral), endopelvic fascia, urethral smooth muscle sues can stretch or tear, providing a mechanism for and vascular plexus, and PFMs.14,15,17 Although all of these pelvic organ prolapse and/or stress UI.17,20 The levator structures are important to continence, physical therapy ani muscles can also be contracted voluntarily during Pubovaginalis m. Pubococcygeus Puborectalis m. Urethra Levator Vagina Iliococcygeus m. ani Arcus Obturator tendineus internus m. Anococcygeal raphe Coccygeus m. Piriformis m. Perineal Sacrum body Anal canal FIGURE 20-1  T​ he pelvic muscles. (From Mathers LH: Clinical anatomy principles. St Louis, 1996, Mosby.)

384 CHAPTER 20  Management of Urinary Incontinence in Women and Men abrupt rises in abdominal pressure (as occurs with a Urge Urinary Incontinence cough or sneeze) to stop urine leakage by compressing the urethra against the symphysis pubis or by preventing The exact cause of urge UI in many cases is unknown. urethral descent.21,22 However, it is estimated that one third of persons with overactive bladder (OAB) suffer from urge UI.38 Overac- In both men and women, the striated urethral sphinc- tive bladder is defined by the International Continence ter plays an important role in continence. It is composed Society as “urgency, with or without urge UI, usually predominately of slow-twitch (type I) muscle fibers. This with frequency and nocturia.”1 Overactive bladder muscle is constantly active and assists continence during symptoms can be caused by low bladder compliance prolonged periods of bladder filling and urine stor- (a high rise in bladder pressure during bladder filling) age.17,23 and/or detrusor overactivity (the presence of involuntary bladder contractions during the filling phase).39 Detrusor PATHOPHYSIOLOGY AND RISK FACTORS overactivity can occur due to idiopathic, neurogenic FOR URINARY INCONTINENCE (associated with a neurologic condition, such as stroke, Parkinson’s disease, multiple sclerosis, brain injury or Stress Urinary Incontinence tumor, spinal cord injury or tumor, or diabetes mellitus), or nonneurogenic (bladder infection, bladder outlet The loss of anatomic support (levator ani muscles, endo- obstruction, bladder tumors, bladder stones, and aging) pelvic fascia, and pelvic ligaments) to the proximal ure- causes.14,39 In women, urethral obstruction secondary to thra is one mechanism of female stress UI. Without pelvic floor organ prolapse (POP) may lead to detrusor support, the bladder neck and/or urethra descend muscle changes and subsequently detrusor overactivity.14 outside the pelvic cavity during increases in intra- In men, obstruction caused by benign or malignant pros- abdominal pressure. Subsequently, the urethra cannot tatic enlargement can result in OAB by altering bladder be sufficiently compressed, abdominal pressure exceeds physiology, neural regulation, restricting bladder empty- urethral pressure, and UI occurs.14,24 ing, and/or affecting PFM strength.40 Following surgical removal of the obstruction (as in RP), the bladder may Childbirth is one factor that predisposes women to continue to be overactive, potentially causing postsurgi- stress UI. Although the exact relationship between cal urge UI.37 Other factors associated with female OAB pregnancy/childbirth and stress UI is unclear, it is typi- and/or urge UI include advancing age, hysterectomy, caf- cally attributed to pudendal nerve injury, stretching/ feine intake greater than 400 mg/day (about 2.5 cups), tearing of the pelvic ligaments and/or levator ani mus- weekly consumption of carbonated drinks, obesity, ar- cles, or damage to the urethra.14 As women age to thritis, and impaired mobility and/or impaired activities 60 years or older, parity is no longer an independent of daily living.3,41-44 risk factor for stress UI.25 Other stress UI risk factors and/or age-related physiological changes in muscle and EXAMINATION connective tissue, such as the decline in collagen content and loss of elasticity, may play a greater role than parity History in the development of stress UI in older women.26 Reported risk factors for female stress UI include age, Given the multifaceted nature of UI, a thorough medi- estrogen loss, Caucasian race, family history of stress cal history should be taken from the patient and/or UI, obesity, smoking, chronic cough/respiratory disease, primary caregiver. The history should also review med- pelvic surgery, chronic constipation, and neurologic ical conditions that influence bladder function directly, disorders.26-31 Men with prostate cancer who undergo and conditions and/or lifestyle factors that precipitate radical prostatectomy (RP) are at great risk of develop- UI (Box 20-1).25,39,44 Surgical history, including ure- ing some form of UI. At least 50% of men experience thral, bladder, bowel, rectal, and prostate (males only) UI immediately following this procedure.32,33 Although should be obtained. An obstetric and gynecologic his- the incidence of UI decreases over time, those who tory should be asked of female clients (see Box 20-1). remain incontinent experience a negative impact on their As impaired mobility and activities of daily living are quality of life.34 Following RP, the proximal urethral risk factors for UI,3,44 conditions leading to functional sphincter, consisting of the bladder neck, prostate, and decline, such as arthritis or pain, should be discussed. prostatic (proximal) urethra, is removed. Consequently, In such cases, patients should be asked whether they continence depends on the integrity of the rhabdosphinc- have difficulty getting out of bed, moving from sitting ter, the distal urethral sphincter.35 Stress UI following to standing, walking, and removing clothing. RP is largely attributed to incompetence of the rhabdo- sphincter.36 Surgery-related scar tissue or pudendal nerve Medications should be reviewed, including those that injury, reduced sphincter mobility secondary to scar alter cognition, fluid balance, and bladder and/or sphinc- tissues, an underdeveloped/weak distal sphincter, and/or ter function. Through various mechanisms, medications weak PFMs are considered possible causes of rhabdo- can directly affect urinary function. Antihypertensives, sphincter incompetence following RP.35-37

CHAPTER 20  Management of Urinary Incontinence in Women and Men 385 B O X 2 0 - 1 Medical Conditions That Affect A careful bladder symptom history is important to Bladder Function Directly identify onset, type, frequency, and severity of symp- toms, precipitating factors, and need for further medical • Congestive heart failure evaluation. History of other pelvic symptoms should • Peripheral venous insufficiency also be obtained. Box 20-2 provides a list of key bladder • Renal disease and bowel symptoms typically asked during a physical • Urinary tract infection therapy examination for UI. For example, pain with • Bladder tumor urination may be a sign of a urinary tract infection. • Bladder stones Straining to urinate and/or incomplete bladder emptying • Bladder outlet obstruction (prostatic or bladder neck in men; may be a symptom of urethral obstruction. Incomplete bladder emptying may be a sign of poor detrusor muscle pelvic organ prolapse, bladder neck, or urethra in women) contractility, which could lead to urinary retention. • Diabetes Patients should be asked whether or not they experience • Neurologic conditions regular constipation, as it is a known risk factor for • Radiation therapy. stress UI.26-29 In addition, dual incontinence (defined as monthly UI and fecal incontinence [FI] within previous Conditions that Can Precipitate Urinary Incontinence year) has been reported to occur in about 8% of women (UI) by Increasing Intraabdominal Pressure and 5% of men with UI.46 As POP can be associated • Chronic cough (chronic obstructive lung disease, smoking, with urge UI,14 female patients should be asked if they sense a bulge or pressure in the vagina. Given the high asthma, allergies, emphysema) prevalence of UI, particularly in women, several key • Constipation • Obesity BOX 20-2 Key Bladder Symptom Questions • Occupation (involving heavy lifting), and/or recreational activities • When did your bladder problem begin? (weightlifting, jogging) • Do you leak urine with laughing, coughing, sneezing, lifting, or Obstetric History exercise?* • Number of pregnancies and deliveries • Do you leak urine on the way to the bathroom?* • Mode of delivery (vaginal versus cesarean delivery; forceps- or • Do you have to strain to empty your bladder?* • Do you feel that your bladder is still not empty after you void?* vacuum-assisted vaginal delivery) • Do you experience pain or burning when you empty your • Episiotomy and/or anal sphincter laceration during delivery • Infant birth weight bladder?* • UI/FI (fecal incontinence) during or following pregnancy. • How often do you empty your bladder during the day? • How often do you wake up at night to empty your bladder? Gynecologic History • How often do you feel a strong desire or urge to urinate that you • Menopausal status (including hormone replacement therapy) • Surgery (hysterectomy, pelvic organ prolapse, and antiincontinence can’t stop? • How often do you leak urine during the day? procedures) • How often do you leak urine when you sleep or wake up to neuroleptics, and benzodiazepines can reduce urethral empty your bladder? pressure. Diuretics are known to increase the production • Do you use any type of absorbent product (pad, adult undergar- of urine. Anticholinergics and b-blockers may affect one’s ability to empty the bladder completely. Other ment)? If yes, how many do you use in a 24-hour period? medications can affect urinary function indirectly via • Do you leak urine during sexual intercourse? their side effects. Constipation, a risk factor for stress UI, • Are your bladder leaks small (drops), medium (wets underwear), is a side effect associated with narcotic analgesic and iron use. Another risk factor for stress UI, cough, is a or large (soaks underwear and outer clothing)? side effect of ACE inhibitors.44,45 Key Bowel Symptom Questions Patients should be asked about their daily fluid • How many bowel movements do you usually have per day? intake. Restricting fluids is a coping strategy used by • Do you experience pain with bowel movements? some to reduce urinary frequency, urgency, and inconti- • Do you experience frequent constipation? How often? nence. However, reducing fluids may lead to constipa- • Do you experience frequent diarrhea? How often? tion or urinary tract infection, thus adversely affecting • How often do you strain to have a bowel movement? continence. Conversely, a patient may report excessive • How often do you experience loss of liquid or solid stool? fluid intake, which may exacerbate bladder symptoms. • Do you need a laxative or enema to produce a bowel movement? Time of fluid intake should be discussed, as consumption of fluids during evening hours may contribute to noctu- *A “yes” response to any of these questions should cause the physical ria (waking one or more times at night to void39). therapist to ask the patient if he or she has sought evaluation or treatment Caffeine, alcohol, and/or carbonated beverage intake for the symptom(s) from his or her primary care physician or a specialist. If should be reviewed to determine if they are contributing the patient has not been evaluated for the symptom(s) by a physician, the to the patient’s UI. physical therapist should refer them to do so.

386 CHAPTER 20  Management of Urinary Incontinence in Women and Men bladder symptom questions in Box 20-2 (identified with BOX 20-3 Components of a Basic Physical an asterisk) should be included in the systems review of Examination for Persons with any physical therapy client. A “yes” response to any of Urinary Incontinence these questions should lead the clinician to ask the patient if he or she has sought evaluation or treatment General Examination for the symptom(s) from his or her primary care physi- • Observation for lower extremity edema cian or a specialist (urologist, gynecologist, or urogyne- • Lower extremity strength and joint mobility cologist). If the patient has not been evaluated for the • Lower extremity sensation symptom(s) by their physician, the physical therapist • Lower extremity reflexes should refer them to do so. • Functional mobility A bladder diary can be used to capture and quantify Specific Examination of Female Clients bladder function, including voiding frequency, volume of Perineal Observation each void, number of UI episodes per day, the size or • Perineal skin for inflammation, excessive vaginal discharge, severity of each UI episode, and daily pad usage.47 The 7-day bladder diary has been shown to have high test– lesions, scars retest reliability for voiding frequency and number of UI • Demonstration of pelvic floor muscle contraction episodes.48 However, some patients may fail to produce a valid bladder diary. In such cases, the clinician may External Examination consider administration of the 3-day bladder diary. • Sensation around the perineum Adherence to keeping a 3-day bladder diary has been • Palpation to identify painful tissues shown to be superior to 7-day recording. In addition, the • Sacral reflexes: anal wink, bulbocavernosal reflex mean number of UI episodes recorded during the first 3 of the 7 days has been shown to be representative of Internal Examination the mean number of UI episodes averaged across the • Sensation within the vagina entire week.49 • Palpation to identify painful tissues • Pelvic floor muscle bulk Physical Examination • Pelvic floor muscle contraction Box 20-3 summarizes the components of a basic physical • Exam rectally if no contraction palpable vaginally therapy examination for persons with UI. For clients • Presence and quantification of pelvic organ prolapse with pelvic pain and/or additional musculoskeletal com- plaints or conditions, a more detailed and comprehen- Specific Examination of Male Clients sive examination of the spine, pelvis, and hips may be Genital Observation warranted. • Irritation of skin or skin breakdown on penis from urine expo- The intent of this chapter is not to instruct the reader sure, genital lesions on how to perform the procedures outlined in Box 20-3. • Demonstration of pelvic floor muscle contraction Therefore, it is recommended that the reader seek con- tinued education and training prior to implementing External Examination specific examination procedures into clinical practice. • Perineal and perianal sensation It is also recommended that the practitioner confirm if • Sacral reflexes: anal wink, bulbocavernosal reflex these examination procedures (particularly the manual pelvic floor examination) falls within their state’s physi- Rectal Examination (After Medical Clearance Postsurgery) cal therapy practice act. • Pelvic floor muscle contraction Quantifying Pelvic Floor Muscle Function.  T​ he most clinically practical method of examining PFM function is obtain a composite score.50 Brink et al reported a compos- through vaginal, digital examination. Two scales, the ite score test–retest reliability coefficient of r 5 0.65 ob- Brink50 and Modified Oxford Grading,51 have been tained from a sample (mean age 5 55.8 years; 82% with described for grading digitally (vaginal) examined PFM mixed UI) of women attending pretreatment clinic visits.50 function. Currently, there is no suggested standard Hundley et al reported good composite score interrater method of assessing PFM trans-anally. reliability (r 5 0.68), and correlations between the Brink pressure subscale score and maximal squeeze pressure The Brink scale (Pelvic Muscle Rating Scale, Version 2) scores obtained using a perineometer (r 5 0.67 and 0.71, is based on three muscle contraction variables: intensity of respectively).52 the “squeeze” generated by the muscle contraction, verti- cal displacement of the examiner’s fingers as the muscles The Modified Oxford scale uses a 6-point numerical lateral to the vagina contract, and muscle contraction scale to grade PFM contraction: 0 5 no contraction (nil), duration. Each variable is rated separately on a 4-point 1 5 flicker, 2 5 weak, 3 5 moderate, 4 5 good (with categorical scale. The three subscale scores are summed to lift), and 5 5 strong.51 Testing young, mostly nulliparous females (mean age of 25 years) without symptoms of pelvic floor dysfunction, Bo and Finckenhagen reported the Oxford scale produced only fair intertester agree- ment. In addition, it lacked the ability to discriminate among women with weak, moderate, good, or strong

CHAPTER 20  Management of Urinary Incontinence in Women and Men 387 muscle contractions when measures were compared undergoing surgery for a variety of pelvic floor disorders against vaginal squeeze pressures obtained from a vagi- (UI, FI, POP). As the PFDI and PFIQ are quite lengthy, nal manometry device.53 Although the Oxford scale is short forms were developed (the PFDI-20 and PFIQ-7) simpler and perhaps easier to use, the Brink scale’s stron- and also found to have good reliability, validity, and ger psychometric properties may provide the clinician responsiveness. In addition, based on global ratings of with a more consistent measurement tool to document improvement defined as at least “a little better” after the patient’s status over time. surgery for pelvic floor disorders, a change of 45 points on the PFDI-20 summary score (summary of the Outcome Measures three scale scores) and a change of 36 points on the PFIQ-7 summary score were found to be clinically Symptoms, symptom-related bother or distress, quality important.58 of life, and sexual function can be measured with condi- tion-specific standardized assessment tools. If these The Pelvic Organ Prolapse and Incontinence Sexual tools are administered at examination and at discharge Function Questionnaire (PISQ) is an internally consis- from physical therapy, they can be used to determine the tent, reliable, and valid condition-specific sexual func- outcome or efficacy of the physical therapy interventions tion questionnaire developed for sexually active women for UI. with UI and/or POP. It contains 31 items to measure sexual function across three domains: Behavior/Emotive, Shumaker et al developed two widely used, internally Physical, and Partner-Related.59 The PISQ-12 is a reli- consistent, reliable, valid, and responsive clinical out- able and valid shortened version of the 31-item PISQ.60 come measures for women with UI, the Urogenital Distress Inventory (UDI) and Incontinence Impact Ques- The University of California–Los Angeles Prostate tionnaire (IIQ). Both questionnaires were tested psycho- Cancer Index is a questionnaire for men with early-stage metrically using a sample of community-dwelling women prostate cancer. Items measure urine leakage, sexual with stress UI or urge UI.54 The UDI contains 19 items function and bother, urinary function and bother, and that measure urinary symptoms (Irritative, Obstructive/ bowel function and bother. It has been shown to have Discomfort, and Stress) and their associated bother. The good internal consistency, test–retest reliability, validity, IIQ is a 30-item questionnaire that measures the health- and moderate responsiveness.61-63 related quality of life (HRQOL) impact of UI across four domains: Physical Activity, Travel, Social Relationships, INTERVENTIONS and Emotional Health.54 Both questionnaires were short- ened to develop the six-item UDI (UDI-6) and seven-item The primary physical therapy interventions for urinary IIQ (IIQ-7). In a sample of community-dwelling women incontinence include those aimed toward improving with stress UI, urge UI, or mixed UI, these shorter ver- PFM function (PFM exercise, biofeedback, and electrical sions were shown to be reliable and valid against the stimulation), and those aimed toward improving bladder longer versions.55 function (bladder training and lifestyle measures). In most cases, patients will require a multicomponent, indi- The reliability of the IIQ-7 has been tested in men vidualized plan of care. In addition, some patients may after RP. It was found to be internally consistent with have already undergone, or plan to undergo, pharmaco- good test–retest reliability, and statistically correlated logic or surgical interventions to reduce their urinary with urine loss measured by pad test and patient symptoms. In the following sections, the theoretical responses to a cancer-specific HRQOL measure, the rationale and current evidence supporting these inter- European Organization for the Research and Treatment ventions will be presented. of Cancer Quality of Life Questionnaire, Version 2.56 The study investigators, however, highly recommended Pelvic Floor Muscle Exercise further validity testing of the IIQ-7 in this particular population.56 Pelvic floor muscle exercise is believed to reduce stress UI by improving urethral closure and pelvic organ support. The Pelvic Floor Distress Inventory (PFDI), developed DeLancey suggested that a properly timed PFM contrac- by Barber et al for women, in many cases, has greater tion can stop stress UI by compressing the urethra clinical utility compared to other UI-specific QOL tools. against the symphysis pubis.21 In addition, exercise- The PFDI is similar to the UDI but measures a greater induced levator ani muscle hypertrophy may improve number and scope of pelvic symptoms, including urethral pressure and structural support of the pelvic Urinary (identical to the UDI), Colorectal (Bowel), and organs, preventing urethral descent during abrupt rises POP.57 Its companion measure, the Pelvic Floor Impact in intra-abdominal pressure.22 Questionnaire (PFIQ),57 measures the impact of these symptoms on HRQOL and includes three impact sub- Several randomized controlled trials and systematic scales: Urinary, Colorectal Anal, and POP. Both the PFDI reviews confirmed the efficacy of PFM exercise as an and PFIQ were found to be internally consistent, reli- intervention for stress UI and mixed UI.64-69 However, able, valid, and demonstrated responsiveness in women definitive cure and improvement rates are difficult to

388 CHAPTER 20  Management of Urinary Incontinence in Women and Men conclude, as a variety of continence outcomes were Earlier in the chapter, the neurourological pathway for applied across studies. For example, Burns et al found a the guarding reflex, the increase in external urethral 16% cure and 44% improvement (50% to 99% reduc- sphincter and PFM activity during bladder filling, was tion in urine loss based on urinary diary) for women described. Clinical studies have also shown that volun- who performed PFM exercises compared to 3% cure tary contraction of the PFMs can inhibit detrusor con- and 15% improvement rates observed in controls.64 tractions, reduce detrusor pressure, and increase urethral Using a self-reported cure/improvement scale, Bo et al pressure.76,77 found that 8% of women were continent, 40% almost continent, and 44% improved as a result of PFM exer- As with stress UI, strong evidence for an optimal cise compared to 3%, 87%, and 10% of controls almost PFM prescription for urge UI is unknown.70 In several continent, unchanged, or worse, respectively.65 Finally, studies, a multicomponent behavioral training program another randomized controlled trial found 65% of that included 45 to 50 PFM contractions/day (working women who performed PFM exercises achieved at least up to a 10-second contraction) was found to reduce UI a 50% reduction in pad test weight compared to 0% of by a mean 76% to 86% in women with urge UI and controls.66 mixed UI.77-79 Pelvic floor muscle exercise variables, including the In persons with OAB or urge UI, using PFM contrac- number of PFM contractions performed/day, contrac- tions to suppress urges and prevent incontinence needs tion duration, and duration of care, differ greatly across to be practiced and learned. The urge-suppression strat- PFM exercise studies.67,68,70 Therefore, it is difficult to egy should be applied during situations that trigger determine an optimal PFM exercise prescription for urges, such as walking to the bathroom.78,79 This strat- women with stress UI. However, several studies that egy will be discussed in more detail in the section on exercised women to improve PFM endurance and power bladder training. have found favorable results. Burns et al required women to perform up to 200 PFM contractions/day. Quick The efficacy of PFM exercise to reduce UI in men fol- 3-second, and sustained 10-second contractions were lowing RP is less clear. A recent, systematic review that prescribed.64 Similarly, Wyman et al asked women to critically examined evidence for postoperative PFM perform five repetitions of a 3-second contraction and exercise found that only one of seven reviewed studies up to 45 repetitions of a 10-second contraction each day. suggested any benefit.80 A great deal of heterogeneity Wyman et al’s protocol resulted in cure for 13% and was observed across trials for baseline UI status among improvement in 56% (a 50% or higher reduction in UI subjects, subject recruitment methods, PFM exercise episodes) of women.71 Bo et al asked women to perform interventions, control interventions, study outcomes, 8 to 12 contractions three times per day. Each contrac- and statistical methods. As a result, the authors were tion was held for 6 to 8 seconds, and three to four fast unable to determine the value of PFM exercise in men contractions were added at the end of each contrac- following RP.80 tion.65 Finally, Borello-France et al reported an overall 67.9% reduction in UI episodes (41% of women were Although an “exact PFM exercise prescription” for cured and another 20.5% had at least a 75% reduction UI cannot be concluded from the literature, it is never- in UI symptoms) following a PFM exercise intervention theless important to reflect upon the available evidence that included a maximum of 60 “fast and strong” (3-sec- when determining a patient’s plan of care. In addition, it ond) and 30 endurance (up to 12-second) PFM contrac- is equally important for the clinician to individualize tions per day.72 exercise to the patient’s needs and situation. In doing so, basic exercise guidelines should be followed. First, the Persons with stress UI also need to learn to contract patient’s initial PFM strength and endurance should be their PFMs during situations that cause urine leakage. considered when prescribing exercise. The total number The skill of contracting the PFMs prior to and during of contractions per day and the contraction/rest duration circumstances of increased abdominal pressure (cough, for each muscle contraction should be progressed gradu- sneeze, laugh, lifting a heavy object) has been termed the ally to prevent muscle fatigue and to promote exercise “stress strategy” or “knack.”73,74 Miller et al showed adherence. Second, the goal, and thus the specific param- that after 1 week of knack instruction only, women with eters of PFM exercise, may differ depending on the mild stress UI reduced UI episodes associated with a patient’s circumstance of UI. For example, a patient with medium and deep cough by 98% and 73%, respec- stress UI episodes will need an exercise program that tively.74 Women with moderate or severe stress UI symp- focuses on building muscle strength and muscle power. toms may need more time before they gain skill in use of To prevent urge UI episodes, the PFMs may need to the knack or “stress strategy.” function differently. A patient with urge UI will need to have adequate muscle coordination and endurance in Pelvic floor muscle exercise also plays an important order to suppress bladder contractions while walking to role in the management of OAB and/or urge UI. The the bathroom. Therefore, the focus of exercise may be to rationale for PFM exercise as an intervention for OAB is promote muscle endurance and coordination. However, partly based on the existence of the “guarding reflex.”75 many patients will have mixed UI and need an exercise program that to some degree addresses all aspects of

CHAPTER 20  Management of Urinary Incontinence in Women and Men 389 muscle function: strength, power, endurance, and coor- exercise alone.42,70,87,88 Therefore, the physical therapist dination. Third, it is important for the patient to be needs to use biofeedback discriminately. It may be most skilled in performing exercises during functional tasks. indicated for persons that poorly understand how to Initially, most patients are advised to exercise in the contract their PFMs, cannot sense or discriminate a cor- supine position. As muscle strength, endurance, and rect PFM contraction, cannot fully relax their muscles coordination improve, they should be advised to exercise following contraction increasing risk of fatigue-induced in upright positions, including sitting and standing. muscle pain, contract muscles other than the PFMs (glu- Eventually, the exercise program needs to be progressed teal and hip adductor muscles), and strain (Valsalva) to include PFM exercises during functional activities while attempting a PFM contraction. (moving from sit to stand; stepping forward, backwards, and sideways; going up a series of steps; or while run- Electrical Stimulation ning in place). General instructions for how to contract PFMs are included in Box 20-4. Electrical stimulation (ES) is an intervention for UI advo- cated by some clinicians. However, there is little scientific Biofeedback evidence to support its use in the treatment of women with stress UI. Proponents of ES for stress UI believe ES Gaining skill in PFM exercise is a struggle for some promotes PFM contraction and increases urethral closure clients. It has been reported that after written or verbal pressure.89 Trials comparing the effectiveness of ES to instruction, only 30% of women are capable of perform- sham ES in women with stress UI have found conflicting ing a correct PFM contraction.81,82 In such situations, results.90-93 However, studies that compared ES with biofeedback may be a useful component of the physical PFM exercise have consistently found no difference in therapy plan of care to promote motor learning. Most stress UI outcomes.65,94 Goode et al94 found no benefit of typically, feedback is obtained using electromyography combining ES and PFM exercise compared to PFM exer- (EMG) and surface electrodes. Surface EMG can be cise alone in the management of women with stress UI recorded from special vaginal or rectal sensors that are and mixed UI. In addition, several unpleasant side effects inserted internally, or from surface electrodes placed associated with ES have been observed, including vaginal externally near the anus. Feedback can also be provided irritation, pain, bleeding, vaginal infection, and urinary verbally from the therapist based on internal digital tract infection.65,90,93,94 As little evidence supports the use palpation of the patient’s PFMs. of ES in the management of female stress UI, it should be used cautiously. Evidence to support the use of ES in the The efficacy of biofeedback-assisted PFM exercise as management of male stress UI has been critically evalu- an intervention for UI has been shown. Across studies of ated and also questioned.95 women with stress UI, biofeedback-assisted PFM exer- cise resulted in a 61% to 91% average decrease in UI Evidence to support the use of ES in women with urge episodes.64,83,84 A similar 76% to 86% mean reduction UI is also limited. The rationale behind the use of ES for of UI has been reported in studies of women and/or men persons with OAB or urge UI is based on studies that with urge UI.78,85,86 observed bladder muscle inhibition following direct pudendal nerve stimulation.96,97 One study of women Studies comparing the efficacy of biofeedback-assisted with mixed UI assigned to receive ES or sham ES found PFM to PFM exercise alone have also been done. no difference between groups across numerous study Numerous systematic reviews and meta-analyses of these outcomes, including number of voids, volume of urine studies have consistently concluded that insufficient sci- loss determined by a pad test, and patient satisfaction.98 entific evidence exists to determine whether PFM exer- Conversely, a study that included men and women with cise augmented with biofeedback is superior to PFM OAB and compared ES to sham ES found those who received ES had greater improved bladder capacity and B O X 2 0 - 4 General Instructions for “How to self-reported UI improvement.99 Finally, in a study of Contract Pelvic Floor Muscles” men following postprostatectomy, those who received 12 weeks of ES alone versus ES plus PFM exercise did • The muscles you need to exercise are those that you would use not differ on voiding, incontinence, or HRQOL out- to prevent the passage of stool or gas from the rectum. You comes. However, both groups in this study rapidly should feel a tightening around the vagina (for females) and improved, making potential between-intervention differ- anus. ences difficult to detect.100 Given this controversial evi- dence, ES should be used sparingly as an intervention for • Never hold your breath when you are doing these exercises. UI. However, persons with stress UI and urge UI need to • Never strain or bear down, like you are trying to produce a develop voluntary PFM control. Therefore, ES may be indicated initially for patients who are unable to activate bowel movement. their PFMs. However, as soon as the patient begins to • Always relax these muscles after each contraction. develop consistent active control of their PFMs, the • Try to relax your buttocks and thigh muscles during exercise. Concentrate on the pelvic floor muscles only.

390 CHAPTER 20  Management of Urinary Incontinence in Women and Men physical therapist should reevaluate the patient’s need improvement observed in the control group. In addition, for ES. women in the bladder training group demonstrated sustained improvement at a 6-month outcome assess- Vaginal Weights ment.105 The benefit of using bladder training in con- junction with PFM exercise is less certain. A compara- Vaginal weights are commercially available and may be tive study of three interventions (bladder training alone, used for the purpose of progressive resistive PFM exer- PFM exercise alone, PFM exercise combined with blad- cise. However, there is little scientific evidence to sug- der training) showed an immediate postintervention gest that vaginal weight training is superior to PFM advantage to combined therapy on the number of incon- exercise in women with stress UI.101 In addition, studies tinent episodes, HRQOL, and treatment satisfaction in a that compared vaginal weight training to PFM exercise sample of women with stress UI, urge UI, and mixed UI. observed poorer adherence and adverse events (muscle However, differences in outcomes between the three fatigue, abdominal pain, vaginitis, and vaginal bleed- interventions did not persist after 3 months.71 ing) for those assigned to the vaginal weight training group.65,102 The efficacy of bladder training as a single interven- tion for men with RP is unclear. One trial that examined Vaginal weights are cone-shaped and sold in sets of a multicomponent behavioral intervention (PFM exer- progressive increments. They are believed to promote cise, voiding schedules, and behavioral methods to man- correct PFM contraction (through feedback sensed about age urgency and postpone voiding) to reduce urge UI cone slippage) and enhance PFM strength (through pro- postprostatectomy showed an 80.7% reduction in symp- gressive resistance training). Women begin using the toms. However, the trial included a small number of heaviest cone they can hold while standing and walking. men, and the combination of interventions made it They are later progressed to heavier cones as tolerated. difficult to draw conclusions regarding the contribution Weights are typically used twice daily for 15 minutes. of bladder training to symptom resolution.85 Behavioral Interventions for Urinary Lifestyle Measures Incontinence Recommendations to alter factors that increase the risk Bladder Training  ​Bladder training is a behavioral inter- for UI are often included in the plan of care for persons vention most often recommended as an intervention for with UI. Scientific evidence upon which to base specific persons with urge UI. The main goals of bladder training recommendations is quite limited. For example, despite are to improve bladder capacity and restore normal its potential to impact general health status, the effect bladder function.103 Burgio described a model in which of smoking cessation on lower urinary tract symptoms the sensation of urgency drives urinary frequency, lead- is not known. However, there is growing evidence to ing to reduced bladder capacity, OAB, and UI. In this support recommendations for weight loss, caffeine model, the introduction of bladder training (expanding reduction, and fluid management. the voiding interval) allows the patient to break the cycle.103 Aside from recommendations to alter known risk factors, clinicians commonly advise patients with OAB Bladder training requires the patient to gradually or urge UI to restrict foods believed to irritate the blad- increase the time interval (usually by 15-minute inter- der (particularly, artificial sweeteners, citrus fruits, veg- vals) between voids until an acceptable voiding schedule etables, and/or juices). However, there is no scientific is reached. A voiding schedule of every 3 to 4 hours is support to justify these recommendations to persons optimal, but depends on the patient’s preintervention with OAB or urge UI.106 voiding schedule. To delay voiding, the patient must be able to suppress the sensation of urgency. Suggested urge Weight Loss suppression strategies include distraction to another (preferably mental) task, taking deep breaths to relax, There is emerging evidence to support weight loss rec- and contracting the PFMs several times to inhibit blad- ommendations as an intervention for female UI. In one der contractions. Patients are also taught to avoid rush- study, morbidly obese women with stress UI and urge UI ing to the bathroom, which may increase abdominal experienced significant improvements in UI following a pressure and trigger bladder contractions. Instead, they weight loss of 45 to 50 kg after bariatric surgery.107 are instructed to walk at a normal pace to the bathroom Remarkably, another study showed that a weight loss of and pausing, if needed, to contract their PFMs.104 only 16 kg by women with stress UI, urge UI, or mixed UI enrolled in a conventional weight loss program Evidence to support the use of bladder training for resulted in a 60% reduction in weekly UI episodes. women with urge UI was demonstrated in a randomized Observed improvements were sustained 6 months fol- controlled trial of women aged 55 years or older. Women lowing the weight reduction intervention. In addition, a who received 6 weeks of bladder training demonstrated 50% reduction in weekly UI episodes was found in a 57% reduction in UI episodes compared to minor

CHAPTER 20  Management of Urinary Incontinence in Women and Men 391 women who lost as little as 5% to 10% of their baseline positive effect of estrogen use on the urethral epithelium, weight.108 subepithelial vascular plexus, and connective tissue pro- moted its use in women with stress UI.116 However, ran- Fluid Management domized clinical trials have found no difference in placebo treatment versus estrogen replacement in reducing stress Many persons with UI restrict fluid intake in an effort to UI symptoms in postmenopausal women. In addition, it manage their UI. There are very few data to support may actually worsen or increase the risk of developing UI recommendations for adjusting fluid intake.106,109 In in some women.117-120 Phenylpropanolamine or PPA, an fact, one study found reducing fluid intake improved UI a-adrenergic agonist, acts to decrease stress UI by increas- episodes in women with either stress UI or idiopathic ing urethral smooth muscle contraction and thus urethral detrusor overactivity, but reduced frequency and ur- closure pressure.121 However, the Food and Drug Admin- gency in only those with detrusor overactivity.110 The istration banned PPA after it was found to increase risk of results of this study should be applied cautiously given hemorrhagic strokes in women taking the drug.122 Finally, the risks associated with restricting fluids, including de- studies have examined the effectiveness of duloxetine, a hydration, constipation, and urinary tract infection.111 serotonin-noradrenalin reuptake inhibitor, in reducing stress UI. Duloxetine increases the tone of the external Some patients with UI will report excessive water urethral sphincter by increasing pudendal nerve output.115 intake and fail to recognize the association between fluid A recent Cochrane review of clinical trials concluded no intake and bladder symptoms. Therefore, a recommen- difference in stress UI cure rates between duloxetine and dation to reduce fluid intake may help improve bladder placebo treatment.115 symptoms, particularly urinary urgency and frequency. Caffeine Reduction Pharmacologic Interventions for Urge Urinary Incontinence Evidence to support caffeine reduction recommenda- tions can be gleaned from clinical trials that tested con- Commonly, patients seeking physical therapy for urge UI comitant interventions to reduce female urge UI. In one may have a current or past history that includes a medi- study, women who consumed more than 100 mg/day of cation for this condition. Therefore, it is important for caffeine either underwent bladder training or bladder the physical therapist to be familiar with these medica- training combined with recommendations and strategies tions and their possible side effects. As described earlier to reduce caffeine. Those in the combined intervention in this chapter, activation of parasympathetic efferents to achieved a 58% (from a mean 238.7 mg/day to a mean the bladder triggers bladder muscle contractions neces- 96.5 mg/day) caffeine reduction and reported statisti- sary to promote voiding. Acetylcholine acts on musca- cally greater improvements in voiding frequency and rinic receptors in the bladder to produce bladder con- urgency episodes compared to women who received tractions.16,116 Anticholinergic drugs are prescribed for bladder training alone.112 The 96.5 mg/day equates to urge UI as they block the parasympathetic acetylcholine less than the caffeine content of a 5-ounce cup of brewed pathway, resulting in bladder muscle inhibition.116,123 coffee (reportedly contains 128 mg caffeine). An 8-oz Anticholinergic drugs are effective in reducing inconti- glass of iced tea and an 8-oz glass of cola soft drink are nence. A recent review concluded that persons taking reported to contain 47 mg and 25 mg of caffeine, respec- anticholinergic medications experienced on average four tively.113 In another multicomponent behavioral inter- fewer UI episodes, five fewer trips to the bathroom per vention study (including caffeine reduction, management day, and moderate improvements in HRQOL.123 of fluid volume, bladder training, and constipation man- agement), 64% of women who reduced caffeine intake Oxybutynin and tolterodine are two anticholinergic were found to have decreased UI episodes.114 medications commonly prescribed by physicians to treat OAB and urge UI. Both drugs are available in immedi- Some patients are very reluctant to reduce their caf- ate- and extended-release formulas.116 Anticholinergic feine intake. Suggesting a trial period of caffeine reduc- drugs have unpleasant side effects, including dry mouth, tion may be more acceptable. In addition, caffeine reduc- dry eyes, blurred vision, constipation, nausea, headache, tion should be done gradually to prevent the patient and dizziness.123 For some patients, side effects are intol- from experiencing severe headaches. erable causing them to discontinue use of the drug. Pharmacologic Interventions for Stress The effectiveness of anticholinergic drugs for UI is not Incontinence age dependent.42,116,123 However, older persons may be at higher risk for developing drug–drug and drug– Medications, including estrogens, a-adrenergic agonists, disease interactions.44 Anticholinergic drugs may inter- and serotonin-noradrenalin reuptake inhibitors, have been act with diseases including dementia, Parkinson’s dis- used to treat women with stress UI. However, there is no ease, hypertensive renal disease, and diabetes.44,124 They universally accepted pharmacotherapy for stress UI.115 The are contraindicated for persons with acute closed- angle glaucoma and are suspected of inducing cognitive