1. Kathleen Lindaman Aebischer PT
50 Shades of Aging
Kathleen Lindaman Aebischer PT
Introduce self, credentials, experience, and type of therapy provided
Story about the purchase of condoms for “work”
Attitude shapes expectations: expect the best outcome and work towards it

2. Much more than you think!
What is the pelvic floor and what does it have to do with my quality of life?
Much more than you think!
What is the pelvic floor and what does it have to do with my quality of life? Much more than you think
We as a society don’t discuss what happens below the belt buckle, especially anything located in the what is considered our “private areas” where the pelvic floor is located.
Many suffer with incontinence, a sense of urgency and frequency as well as pain that may prevent sexual expression. On average, once we overcome our embarrassment and discomfort, and seek medical help, it may take up to 2 years to find a provider who is able to treat our signs and symptoms.
Only 38% of men and 22% of women discuss sexual problems with their physician. That is a very low number considering it is an integral part of our lives
By the end of this presentation you should be able to understand what the pelvic floor is, its function, changes with aging, and what happens when something goes wrong
You will also have a basic knowledge of some preventative measures to improve the quality of life as you age

3. Statistics
2010
40 million adults over the age of 65 (12.9% of the population)
53,364 adults are greater than 100 yrs old (.13% of the population)
2030
Estimated 72 million over the age of 65 (19% of the population)
40 million over the age of 65 (12.9% of population)
53,000 are over the age of 100
By 2030 the estimated population of seniors will grow to 72 million or 19% of the population

4. Life Expectancy
Adults over the age of 65 have an average lift expectancy of 78.2 yrs with women living 20 yrs more on average and men only 17 yrs on average
The average lift expectancy is 78.2 yrs old with women living approximately 3 yrs longer then men
Older women outnumber men 23 million to 17.5 million

5. Who do The Seniors Live with?
72% of older men and 42% of older women live with spouses at home
Widows account for 8.7 million of the population and widowers 2.1 million
29% over the age of 65 live alone
72% of older men and 42% of older women live with their spouse at home
Widows number 4x greater in number than widowers
29% of the population live alone and
Almost ½ million over the age of 65 are primary care givers for grandchildren

6. Nursing Homes
Only 1.5 million (4.1% of the population) live in nursing facilities
We all have an image of large numbers of elderly Living in nursing facilities, but it’s a relatively low percentage
They generally need assistance in 3 or more major activities of daily living such as toileting, bathing, dressing, eating, ambulating, meal prep, and assistance with medications and medical care
This contrasts with those who live at home either independently or with family / agency assistance and have deficits in only one or two of the major ADLs

7. 2009 Seniors Living Outside Nursing Facilities
40% rate their health as excellent or very good despite having at least one chronic medical condition
37% of those over 65 categorize themselves as having a disability vs. being disabled
Seniors living at home 40% rate health excellent or very good:
most have at least one chronic condition: uncontrolled HTN, diabetes, arthritis, heart disease, cancer, or sinusitis
Major disability: hearing, vision, cognition, ambulation, and self care needing assist of family or outside agencies to live at home

8. A Much Larger Segment of Seniors
17.4% over the age of 65 are working or seeking work (6.7 million)
A larger % of seniors are in the work force then are in nursing homes
Work is a choice vs. out of necessity. When asked, seniors state they work to stay mentally sharp and physically active

9. Views on Retirement
59% view retirement as a time to be active and involved
Only 24% see retirement as a time to relax and enjoy leisure
59% see retirement as a time of activity and being involved.
set new goals and explore new activities or second careers
Only 24% see it as a time to relax and enjoy leisure

10. Older Volunteers
46.6% of seniors from 65 to 74 volunteer in their communities
43% of those 75+ yrs old also volunteer
Almost 47% seniors 65 to 74 volunteer in their communities
43% over 75 volunteer as well
The hours volunteered by older adults are almost twice the national average
56 hrs/yr for younger adults AND 96 hours/yr seniors

11. The next generation retirees will be the healthiest and longest lived with 40% of the population expected to reach 90 by 2050
The upcoming generation of retirees will be the healthiest and longest lived
40% expected to each 90 by 2050

12. How Do We Get To That Healthy
Vigorous Life of Possibilities ?
How do we get to the health, vigorous life of possibilities?
First we have to understand the changes with aging

13. General Changes as We Age
Loss of Muscle Mass
Weight gain
Decreased skin elasticity
Loss of height
Loss of bladder capacity
Stiffening of the joints and ligaments
Loss of muscle mass as we age
Btw 40 and 70 muscle strength drops 10 to 20%
and it drops 30-40% btw 70 and 80
It leads to weight gain into the sixties for women, and only into the 50s for men; men also have the advantage again as they start with a larger muscle mass then women
Skin has decreased blood supply, decreased collagen , a reduction in immunity cell leaving skin wrinkled, rough, yellowed, leathery, and spotted
As we age, the discs in our backs dry out and shrink, by age 80 we lose 2 inches of height
The arches flatten, the spine curves, and hip and knee joints change angles
Loss of bladder capacity occurs over the age of 65. Seniors normally have to get up during the night to urinate once
Most of us begin to lose flexibility as early as in our late teens and continues to worsen as we age

14. General Changes with Aging
Decreased circulation
Glucose tolerance deteriorates
Bones become more brittle
There is a decrease in the immune response effectiveness
Decreased circulation leads to decreased endurance and stamina as well as being cold due to decreased circulating oxygen
Insulin efficacy decreases, and less glucose is delivered to the cells for energy leading to a higher rate of diabetes
Less new bone growth occurs and bones become more brittle. Osteopenia, weakening of the bone occurs when bone becomes less dense and can lead to osteoporosis, a serious condition. There is a higher incident of spinal compression fractures, hip and wrist fractures
Healing rates slow due to a decrease immune response that protects us from bacteria, viruses, and other infections

15. Many of these conditions can be improved or slowed by remaining active
Regular exercise
Stretching, aerobics, and strengthening
Many of these conditions can be prevented, improved or deterioration slowed by remaining active with a healthy diet
Stretching maintains and restores flexibility to the joints and muscles decreasing stiffness and pain
slows the deterioration of the joints (arthritis) by maintaining good joint mechanics
Aerobics burn fat, improves circulation, and improves oxygen delivery to the tissues
Strengthening of muscles increases muscle mass, providing more cells to burn full, control weight, and strengthens bone

16. Dietary Changes Slow Aging
Dietary Changes slow aging, lower risks of HTN, cardiovascular disease, diabetes, and stroke
Low in saturated and hydrogenated fats
Low in processed carbohydrates and sugars
High in fiber
High in Calcium with vitamin D2
High in nutrients and minerals
These changes are not going to be covered today in this presentation but dietary changes are being covered in the Anti-inflammatory Med.

17. Sexuality and Aging
Interest and pleasure in sex does not decrease in healthy aging adults but sexual behavior does decline
Sex remains a way to communicate love, affection, warmth, sharing and bonding
Interest in sex does not decline with aging for healthy seniors but sexual behaviors decrease by 5% per yr for women and 8% per yr for men after the age of 50
Sex expresses love, affection, warmth, sharing and bonding
73% population are sexually active ages 57-64
53% seniors are sexually active ages 65-74
26% seniors are sexually active 75-85
Those who report their overall health as poor are less likely to be sexually active
In retirement communities there are more women then men and competition for companionship is fierce; there is a growing number of STDs as the men in the communities have multiple partners and 2/3rds of sexually active seniors do not practice safe sex. They think of condom use for birth control instead of as a method of practicing safe sex.

18. Benefits of Sex Sex burns fat Boosts the immune system
Releases brain endorphins
Relieves stress
Slows the pronounced changes that occurs with aging
Improves flexibility of the tissues
Improves body image
Sex burns fat
Boosts the immune system
Releases brain endorphins
Relieves stress
Slows the pronounced changes that occurs with aging
Improves body image
The more sexually active someone is, the more they want to remain sexually active: it increases blood flow, decreases atrophy, and lubricates tissues

19. Aging Changes Specific To Women
Low sexual desire/sex drive
Pain due to illness
Lack of mobility
Medications
Poor body Image
Depression
Fatigue and stress
Slower sexual arousal
Low testosterone
Low sex drive
Pain due to illness/lack of mobility: arthritis, stroke, and other nerve, muscle and bone problems. Mechanics of how the physical act is completed must be changed and the energy cost goes up. Stretching and exercise helps mitigate these changes
Medication: HTN, anti-histamines, anti-depressants, tranquilizers, appetite suppressants, ulcer drugs; Discuss medications with your physician and pharmacist
Alcohol
Poor body image:
Depression, fatigue, and stress
Slower Arousal
Low testosterone and other hormonal changes: A small percentage of physicians do give post menopausal women testosterone treatments as an off label use for improving sexual drive but estrogen replacement is also given; Not for anyone with a history of an estrogen dependent cancer and long term affects and safety are not known

20. Menopause The largest change in aging for women Symptoms Hot flashes
Worsening of organ prolapse
Incontinence, urgency, frequency
Frequent urinary tract infections
Vaginal dryness
Menopause
We live 1/3rd of life in the post menopausal stage and it’s the largest change in aging for women
Symptoms
Hot flashes can be treated with estrogen therapy
Worsening of organ prolapse due to loss of tissue engorgement and decreased support of the pelvic organs
Incontinence, urgency, frequency due to more pressure on the pelvic floor
Behavioral Therapy such as Physical Therapy, biofeedback, and exercise combined with dietary changes can assist in preventing worsening of organ prolapse, and urinary S & S in 80% of the population. Others may need surgery to repair their organ prolapse: cystocele, rectocele, and uterine prolapse as well as vaginal vault prolapse
Frequent infections: the vagina is less acidic and the good bacteria that live there die off and harmful bacteria flourishes leading to yellowish discharge that irritate the skin and leaves the tissue more prone to tearing and becoming infected

21. Lack of Estrogen Causes a cascade of physical changes in the body
Lean fit women are at more risk for post menopausal problems associated with lack of estrogen
Lack of Estrogen
Post menopausal: the production of the hormone estrogen decreases significantly leading to a cascade of physical changes in the body
Lean fit women are at more risk for post menopausal problems associated with lack of estrogen: estrogen is manufactured and stored in our fat cells

22. Atrophic Vaginitis The vagina shortens and becomes more narrow
The tissue is thinner with loss of elasticity
Vaginal dryness
Intercourse is painful for 25 to 45% of post menopausal women
The vagina shortens and becomes more narrow
The tissue is thinner with loss of elasticity and combined with vaginal dryness can cause bleeding and pain with intercourse and examinations
Intercourse is painful for 25 to 45% of post menopausal women. When sex hurts, it is avoided and this loss of intimacy may jeopardize relationships
Other signs and symptoms: itching, burning, burning with urination, urinary urgency, frequency, UTIs and yeast infections

23. Treatments Vaginal moisturizers Dilators Vibrator use Lubricants
Replens
Dilators
Purchased sets / Candles
Vibrator use
Lubricants
Vaginal moisturizers
Replens
Dilators
Purchased sets / Candles
Vibrator use increases circulation and improves tissue elasticity
Lubricants: many petroleum based lubricants can damage latex condoms

24. Local estrogen treatment
Vaginal estrogen creams such as Estrace and Premarin
Vaginal tablets such as Vagifem
Vaginal estrogen rings such as Estring
Vaginal suppositories
Localized estrogen treatment first choice as very little is absorbed into the blood stream and most stays in the vaginal tissue
Vaginal estrogen creams such as Estrace and Premarin
Vaginal tablets such as Vagifem
Vaginal estrogen rings such as Estring
Vaginal suppositories

25. Systemic estrogen treatments
Estrogen is absorbed into the blood stream and reaches all the tissues
Estrogen patches
Hormonal Replacement Therapy or HRT oral estrogen replacements
Homeopathic remedies
Systemic estrogen treatments are utilized only when local treatment is not effective. The
Estrogen patches
Hormonal Replacement Therapy or HRT oral estrogen replacements
Homeopathic remedies

26. Side Effects Vary Headache Stomach upset, bloating, nausea
Weight changes
Breast tenderness
Back and abdominal pain
Respiratory infections
Vaginal itching or yeast infections
Change in sexual interest
Headache
Stomach upset, bloating, nausea
Weight changes
Breast tenderness
Back and abdominal pain
Respiratory infections
Vaginal itching or yeast infections
Change in sexual interest

27. Vaginal Irritants Soaps and laundry detergents with dyes and perfumes
Lotions
Douches
Condom use
Smoking
Soaps and laundry detergents with dyes and perfumes
Lotions
Douches: not recommended due to the changes in the acidity of the vagina
Condom use
Smoking
Non cotton underwear that doesn’t allow the tissue to breathe
Wearing bathing suits for prolonged periods of time
Swimming in chlorinated pools

28. Preventative Measures
Use natural oils to hydrate the tissue in the vulva (area between the inner vaginal lips)
Exercise regularly including stretching, aerobics, and strengthening
Maintain a healthy diet
Work on loving the body you are in
Use natural oils to hydrate the tissue in the vulva (area between the inner vaginal lips)
Vitamin E, Safflower, Coconut or olive oil used 3-4x/week for several months hydrates and heals tears in the vaginal tissue and vulva
Exercise regularly including stretching, aerobics, and strengthening
Maintain a healthy diet
Work on loving the body you are in

29. Use It Or Lose It! AND Use it or lose it Sex increases blood supply
The more vaginal penetration occurs, the more elastic the tissue stays
The more sex you have, the more sex hormones are produced, improving vaginal lubrication and tissue health
Better sense of well being

30. Pelvic Floor Function Supports the internal organs
Assists the round sphincter muscles in clamping tubes so we don’t loose urine or feces
Assists with sexual function
Supports the internal organs: the muscles run from front to back and side to side forming a hammock in the lower pelvis
-Assists the round sphincter muscles in clamping tubes so we don’t loose urine or feces
-Assists with sexual function
-Understanding pelvic anatomy helps us to understand function and the DYSFUNCTION when things go wrong
-Lithotomy position
-Labia Majora: large lips
Labia Minora: inner lips
-Vestibule area inside
-Clitoris sexual organ of arousal and orgasm
-Urethra opening for urination
-Introitus or opening to the vagina

31. Pelvic Floor Muscles 3 muscle layers
Superficial External Genital Muscles
Urogenital layer (Perineal Membrane)
Pelvic layer
3 Diaphragms
Superficial External Genital Muscles
Urogenital Diaphragm (Perineal Membrane)
Pelvic Diaphragm

32. -Urogenital triangle
-anal triangle
-EAS
-IAS

33. Supportive Dysfunctions
Incontinence
Stress
Urge
Mixed
Overflow
Treatment
Physical Therapy
Medication
Botox and other injections
Surgery
PT Treatment
Joint alignment
Biofeedback
Postural education
Bowel and bladder retraining
Strengthening core and pelvic floor
Electric stimulation

34. Supportive Dysfunctions
Organ Prolapse
Uterine prolapse
Bladder prolapse
Rectal prolapse
Vaginal vault prolapse
Treatment
Physical Therapy
Pessary use
Surgery
PT Treatment
Joint alignment
Biofeedback
Postural education
Bowel and bladder retraining
Strengthening core and pelvic floor
Electric stimulation

35. Signs and Symptoms of Supportive Pelvic Dysfunctions
Painful intercourse (dyspareunia)
Pressure against the vaginal wall
Full feeling in the lower belly
Groin stretching pain
Feeling like something is falling out of the vagina
Incontinence
S & S Supportive Dysfunction
Painful intercourse (dyspareunia)
Pressure against the vaginal wall
Full feeling in the lower belly
Groin stretching pain
Feeling like something is falling out of the vagina
Incontinence

39. Contributing Factors to Supportive Pelvic Dysfunctions
Obesity
Long lasting coughing bouts
Frequent constipation
Pelvic Organ tumors
Difficult vaginal delivery
Contributing factors
Obesity
Long lasting coughing bouts
Frequent constipation
Pelvic Organ tumors
Difficult vaginal delivery

40. Hypertonus Pain Dysfunction
Signs and Symptoms
Pain
Dyspareunia/sexual dysfunction
Difficulty with defection/urination
Difficulty with sitting
-Muscle tone is like a good firm hand shake,
ready to contract or relax at any given time. The limp fish hand shake is low tone and its not functional as it has too tighten up too much before it can be useful and never makes it. High tone is the bruising crushing hand shake. It can’t tighten any more so its not functional and is actually tight but weak and it can’t relax
-Tighten your fist and hold it clenched. Feel the changes?
IC, vulvadynia, levator ani syndrome, tension myalgia, protaglia fugax, vaginismus, anismus, coccydynia, and pelvic congestion syndrome
There is also a chronic pain syndrome where the Pudendal nerve is irritated and fires when it should not. All stimuli such as pressure, light touch, clothing rubbing are perceived as severe pain that is burning and itching in nature. “Like the worst yeast infection that never goes away”

41. Hypertonus Treatments
Relaxation and biofeedback
Physical Therapy
Trigger point injections
Epidurals
Anti-depressant medication
Pain medications and regular muscle relaxants do not work well on the pelvic floor
Hypertonus treatments
Relaxation and biofeedback
Trigger point injections
Epidurals
Anti-depressant medication
Pain medications and regular muscle relaxants do not work well on the pelvic floor
Physical Therapy
Joint alignment
Muscle relaxation then strengthening
Biofeedback
Postural education
Soft tissue/Visceral mobilization: TP release
Strain/counter strain
Accessory muscle augmentation
Behavorial training

42. Hypertonus Contributing Factors
History of rape, abuse or incest
Post surgical pain
Scar tissue restrictions
Fractures of the coccyx (tailbone)
Pain due to hemorrhoids or severe constipation
Unknown
History of rape, abuse or incest
Post surgical pain
Scar tissue restrictions
Fractures of the coccyx (tailbone)
Pain due to hemorrhoids or severe constipation
Unknown

44. Incoordination (Muscle Dys-synergy)
Inappropriate use of muscles of the pelvic floor and core
Inappropriate use of the muscles of the pelvic floor and core

45. S & S of Muscle Incoordination
Val salva
Improper tissue contractility
Neurologic disorders
Adhesions
CNS disorders
Disuse

46. Contributing Factors Incoordination/Disuse Dysfunction
Lack of awareness:
Weakness, lack of coordination of muscles
Muscle disuse atrophy
Muscle imbalances: post-op reconstruction,
Lack of training
Neurological diseases
Lack of awareness: decreased proprioception and kinesthesia
Weakness, lack of coordination of function
Muscle disuse atrophy, incontinence (stress, urge, mixed), fecal incontinence, sexual dysfunction
Muscle imbalances, post-op reconstruction, lack of training, neurological diseases

47. Incoordination Treatment
Physical Therapy
Muscle re-education
Muscle coordination
Relaxation
Postural education
Electric stimulation
Biofeedback
Neuromuscular re-education
Muscle balancing
Muscle relaxation
Biofeedback
Diaphragmatic breathing
Postural education
Soft tissue mobilization
Electric stimulation

48. Visceral Pelvic Dysfunction
Abnormal mobility of the pelvic organs
Endometriosis is the most common cause
Adhesions, trauma, surgery and childbirth
Congenital muscle imbalances
Abnormal mobility of the pelvic organs due to
Adhesions, trauma, surgery, childbirth
Endometriosis which is the most common

49. S & S of Visceral Dysfunction
Weakness
Decreased sensation
Constipation or diarrhea, or both
Flatulence
Pain in the back, abdomen, thigh and leg
S & S of Visceral Dysfunction
Weakness, decreased sensation, bowel/bladder difficulties, constipation, diarrhea, flatulence, pain in the back, abdomen, thigh and leg
Causes: congenital, muscle imbalances, tissue changes due to trauma/surgery, disease, childbirth

50. Visceral Dysfunction Treatment
Physical Therapy
Acupuncture
Surgery
Hormonal Treatment
Visceral Dysfunction treatment
Physical Therapy
Neuromuscular Re-education
Muscle relaxation
Biofeedback
Electric stimulation
Visceral mobilization
Myofascial release
Acupuncture
Surgery
Hormonal Treatment

51. Incontinence
What population has the greatest % of incontinence in women?
Treatment (Physical Therapy)
Behavioral Therapy
Toileting schedules
Dietary changes
Pelvic floor and core exercises
Biofeedback
Coordination of exercise
Incontinence Is not a normal part of aging
Strengthening exercises: isolation of the pelvic floor, then with accessory muscles
Postural exercise/core strengthening
Neuromuscular re-education: abdominal use and avoidance of val salva
Biofeedback
Dietary changes
Toileting schedules
Education about product use

52. Treatment continued Teach how to avoid holding your breath and why
Pessary use
Surgery for bladder suspension
Injections
Val Salva: holding your breath is bad on many levels
Increased disc pressures in the back
Decreases the blood supply to the heart
Reflex turns off the pelvic floor when you need to to work
Pessary use
Surgery
Injections

53. Our perception and attitude toward any situation will determine the outcome!