Central nervous system damage or disease can have a significant negative impact on pelvic organ and pelvic muscle function, adding to the functional burden that we may observe with movement, ADL, and communication/cognition deficits. The intricacies of central nervous system involvement in pelvic organ function can be traced back to our early years of development. Learning to walk and talk as a child happens before the ability to control our bladder and bowel emptying. This level of control requires a well-developed, intricately organized central and autonomic nervous system. It is understandable then, that even minor damage to our central nervous system and nerve pathways can compromise the intricacies of the complexly integrated pelvic viscera and pelvic floor dynamic.

Neurogenic bladder, bowel, and sexual dysfunction are generally defined as an impairment in these organs that results from neurologic damage or disease. The prevalence of neurogenic bladder, bowel, and sexual dysfunction is somewhat uncertain due to limited studies in the neurologic population, however, typically the reports present a wide range. Neurogenic pelvic impairments can be highly variable and dependent on several factors including, but not limited to, lesion level, traumatic etiology (i.e., head, or spinal cord injury), non-traumatic etiology (i.e., stroke, Parkinson’s, Multiple Sclerosis), and comorbidities. The complexity of the person with a central nervous system pathology, whether it be damage or disease, can challenge even the most experienced clinician, and evaluating and treating these individuals can seem like a daunting and intimidating endeavor. Additionally, therapeutic intervention studies in the neurologic population are also less abundant, and individuals with neurologic deficits are often excluded.

Understanding your patient’s neurologic diagnosis, level of injury and corresponding probable neurological system impairments can help you decide on the best assessment and intervention strategy for your patient. Let’s first consider an upper motor neuron (UMN) lesion. This type of lesion can occur in the cortex and even down through the spinal cord descending motor tracts, which are located in the columns of the spinal cord. These individuals typically experience predominant bladder storage dysfunction or detrusor overactivity, increased muscle tone/spasticity in the pelvic floor, and reflexive bowel function. In contrast, a lower motor neuron (LMN) lesion can occur anywhere along the spinal cord within the LMN cell bodies in the anterior horns, along the pathway of a peripheral motor nerve, or at the motor neuromuscular junction. These individuals typically experience bladder storage or voiding symptoms, possible elevated post-void residuals if injury affects the sacral reflex arc, pelvic floor laxity or weakness, impaired descending and rectosigmoid transit, and areflexive bowel function.

Erica Vitek, MOT, OTR, BCB-PMD, PRPC has attended extensive post-graduate rehabilitation education in the area of Parkinson disease and exercise. She is certified in LSVT (Lee Silverman Voice Treatment) BIG and is a trained PWR! (Parkinson Wellness Recovery) provider, both focusing on intensive, amplitude, and neuroplasticity-based exercise programs for people with Parkinson disease. You can learn more about this topic in Erica's remote course, Parkinson Disease and Pelvic Rehabilitation scheduled for April 19-20, 2024.

Parkinson disease (PD) is the second most common neurodegenerative disorder. It is typically characterized by its cardinal motor symptoms of resting tremor, bradykinesia, and rigidity. A myriad of non-motor symptoms accompanies the motor symptoms with constipation being one of the most frequent, affecting nearly 80% of people with PD. Constipation has been labeled a prodromal symptom appearing, in some, up to 20 years pre-diagnosis. It is theorized that there are two neuropathological subtypes of PD, “brain first" and “body first."  The "brain first" subtype is characterized by central nervous system degeneration in the area of the brain that produces dopamine which results in characteristic cardinal motor system dysfunction.  In the “body first” subtype, the peripheral autonomic nervous system and enteric nervous system are said to be affected by the neurodegeneration which then spreads to the brain via the vagus nerve.

Many studies have linked greater non-motor symptom severity with the presence of constipation and irritable bowel syndrome (Tai, Y.C., et al., 2023; Yu Q.J., et al. 2018). The authors report that people with PD and Irritable bowel syndrome (IBS) have greater non-motor symptom severity than those without IBS; the severity of IBS positively correlated with non-motor symptom severity especially mood disorders and the severity of constipation correlated with the severity of motor dysfunction. In another recent study by Al-Wardat et al. 2024, the authors explored a link between constipation and pain experienced in people with PD. The prevalence of people with PD experiencing pain is 40-88%. The neuropathological mechanism is complex and multifactorial however altered pain processing due to abnormalities in neurotransmitters related to PD may impair endogenous pain modulation. Additionally, people with PD, during dopamine replacement therapy off-times, have been shown to have increased spinal nociceptive activity and decreased ascending inhibition lowering their pain thresholds. This demonstrates how neurodegeneration in the brain and enteric nervous system, which may be enhanced by constipation, contributes to non-motor symptom severity.

Erica Vitek, MOT, OTR, BCB-PMD, PRPC has attended extensive post-graduate rehabilitation education in the area of Parkinson disease and exercise. She is certified in LSVT (Lee Silverman Voice Treatment) BIG and is a trained PWR! (Parkinson Wellness Recovery) provider, both focusing on intensive, amplitude, and neuroplasticity-based exercise programs for people with Parkinson disease. You can learn more about this topic in Erica's remote course, Parkinson Disease and Pelvic Rehabilitation.

Does the person with Parkinson disease sense where to contract their pelvic floor and the level of contraction they need to overcome the strength of the urge they experience? The sensorimotor deficit that we can visually observe as degradation in movement amplitude in the limb motor system, for example shuffling steps and micrographia, is also suspect in the pelvic floor.  Also, consider the lengthening of the pelvic floor that must occur for emptying the bowels.  Adequate descent amplitude of the pelvic floor and proper coordination with the abdomen to do so may also not be sensed.  Further, strengthening of the pelvic floor is an effective technique for improved sexual health functioning, but may also be challenged by impaired sensorimotor feedback.  Treatment of this sensorimotor mismatch in the pelvic floor in a person with Parkinson disease requires specialized expertise and feedback from an OT or PT who treats pelvic floor dysfunction and understands how the neurodegeneration affects their abilities. 

When most people think about people with Parkinson disease, they think about stooped posture, shuffling gait, slow and rigid movement, balance difficulties, and tremoring. Often these motor symptoms are the main target of pharmacological treatments with neurologists and many experience positive functional gains. Non-motor symptoms, however, can be more disabling than motor symptoms and have significant adverse effects on the quality of life in people with Parkinson disease.

Erica Vitek, MOT, OTR, BCB-PMD, PRPC has attended extensive post-graduate rehabilitation education in the area of Parkinson disease and exercise. She is certified in LSVT (Lee Silverman Voice Treatment) BIG and is a trained PWR! (Parkinson Wellness Recovery) provider, both focusing on intensive, amplitude, and neuroplasticity-based exercise programs for people with Parkinson disease. Erica has taken a special interest in the unique pelvic floor, bladder, bowel, and sexual health issues experienced by individuals diagnosed with Parkinson disease. You can learn more about this topic in Erica's course, Parkinson Disease and Pelvic Rehabilitation, scheduled for July 23-24, 2021.

Parkinson disease (PD) non-motor symptoms can be even more impactful on quality of life than the cardinal motor symptoms most are familiar with, bradykinesia, rigidity, tremor, and postural instability. The list of non-motor symptoms is extensive affecting many body systems including cognitive, sensory, and autonomic.

Constipation is one of the most common autonomic non-motor symptoms experienced by people with Parkinson disease with studies showing 20-89% prevalence (1). As the disease progresses, individuals are more likely to experience symptoms that suggest a strong relationship between neurodegeneration and bowel dysfunction, such as, decreased frequency of bowel movements, difficulty expelling stool, and diarrhea (2). Constipation has also been hypothesized to be an early indicator for the development of Parkinson disease, and there is ongoing research in this area. It has yet to be shown that constipation is specific enough to predict the development of PD.  

Parkinson disease is the second most common neurologic disorder. When most people think about people with Parkinson disease, they think about stooped posture, shuffling gait, slow and rigid movement, balance difficulties and tremoring. Often these motor symptoms are the main target of pharmacological treatments with neurologists and many experience positive functional gains. Non-motor symptoms, however, can be more disabling than the motor symptoms and have significant adverse effects on the quality of life in people with Parkinson disease.

The pharmacologic management of non-motor autonomic dysfunction, including urinary, bowel, and sexual health impairments, is often ineffective, not supported by adequate research, or causes intolerable side effects for people with Parkinson disease. In a recent article titled “Update on Treatments for Nonmotor Symptoms of Parkinson’s Disease – An Evidence-Based Medicine Review.” Seppi, K, et al., 2019, the authors state this about use of a pharmacological treatment approach - “Before attempting any treatment for lower urinary tract symptoms, urinary tract infections, prostate disease in men, and pelvic floor disease in women should be ruled out.” It is rare to see a mention of pelvic floor within the literature that addresses helping people with Parkinson disease.

Pelvic rehabilitation specialists have a unique opportunity to step in and help these individuals improve their quality of life and many neurologists are unaware of the benefits our services could provide for their patients.

Erica Vitek, MOT, OTR, BCB-PMD, PRPC is the author and presenter of the new Parkinson Disease and Pelvic Rehabilitation course, and she is the co-author of the Neurologic Conditions and Pelvic Floor Rehab course. She is a certified LSVT (Lee Silverman) provider and faculty member, and is a trained PWR! (Parkinson’s Wellness Recovery) provider, both focusing on intensive, amplitude and neuroplasticity based exercise programs for people with Parkinson disease. Erica partners with the Wisconsin Parkinson Association (WPA) as a support group and event presenter as well as author in their publication, The Network. Erica has taken a special interest in the unique pelvic floor, bladder, bowel and sexual health issues experienced by individuals diagnosed with Parkinson disease.

Parkinson disease is the second most common neurologic disorder. When most people think about people with Parkinson disease, they think about stooped posture, shuffling gait, slow and rigid movement, balance difficulties and tremoring. Often these motor symptoms are the main target of pharmacological treatments with neurologists and many experience positive functional gains. Non-motor symptoms, however, can be more disabling than the motor symptoms and have significant adverse effects on the quality of life in people with Parkinson disease.

The pharmacologic management of non-motor autonomic dysfunction, including urinary, bowel, and sexual health impairments, is often ineffective, not supported by adequate research, or causes intolerable side effects for people with Parkinson disease. In a recent article titled Update on Treatments for Nonmotor Symptoms of Parkinson’s Disease – An Evidence-Based Medicine Review ^{Seppi, K, et al., 2019}, the authors state that “before attempting any [pharmacological] treatment for lower urinary tract symptoms, urinary tract infections, prostate disease in men, and pelvic floor disease in women should be ruled out.” It is rare to see a mention of pelvic floor within the literature that addresses helping people with Parkinson disease.

Tibial nerve stimulation has been shown in the literature to be effective for individuals experiencing idiopathic overactive bladder in randomized controlled trials. A systematic review was performed by Schneider, M.P. et al. in 2015 looking at safety and efficacy of its use in neurogenic lower urinary tract dysfunction. Many variables were examined in this review, which included 16 studies after exclusion. The review looked at:

1. Acute stimulation (used during urodynamic assessment only)
2. Chronic stimulation (6-12 weeks of daily-weekly use)
3. Percutaneous or transcutaneous (frequencies, pulse widths, perception thresholds, durations)
4. Urodynamic parameter changes baseline to post treatment
5. Post void residual changes
6. Bladder diary variables
7. Patient adherence to tibial nerve stimulation
8. Any adverse events

The exact mechanism of these types of neuromodulation stimulation procedures remains unclear, however it does appear to play a role in neuroplastic reorganization of cortical networks via peripheral afferents. No specific literature is currently available for the mechanism on action related to neurogenic lower urinary tract dysfunction. Different applications of neuromodulation however have been studied in the neurogenic populations.

One of the randomized controlled trials they report on included 13 people with Parkinson disease. The researchers looked at a comparison between the use of transcutaneous tibial nerve stimulation (n = 8) and sham transcutaneous tibial nerve stimulation (n=5). Transcutaneous tibial nerve stimulation (TTNS) or sham stimulation was delivered to the people with Parkinson disease 2x/week for 5 weeks, 30-minute sessions (10 total sessions). Unilateral electrode placement was utilized, first electrode applied below the left medial malleolus and second electrode 5 cm cephalad. Confirmation of placement was obtained with left great toe plantar flexion. It is important to note the use of the stimulation intensity is reduced to below the motor threshold during the active treatment to direct the stimulation via peripheral afferents.

Akinesia is a term typically used to describe the movement dysfunction observed in people with Parkinson disease. It is defined as a poverty of movement, an impairment or loss of the power to move, and a slowness in movement initiation. There is an observable loss of facial expression, loss of associated nonverbal communicative movements, loss of arm swing with gait, and overall small amplitude movements throughout all skeletal muscles in the body. The cause of this characteristic profile of movement is due to loss of dopamine production in the brain which causes a lack of cortical stimulation for movement.

If the loss of dopamine production in the brain causes this poverty of movement in all skeletal muscles the body, how does the pelvic floor function in the person with Parkinson disease and what should the pelvic floor rehabilitation professional know about treating the pelvic floor in this population of patients?

Let’s take a closer look referencing a very telling article about Parkinson disease and skeletal muscle function. In the Italian town of L’Aquila, a major devastating 6-point Richter scale earthquake occurred on April 6, 2009. 309 people died and there was destruction and collapse of many historical structures, some greater than 100 years old. The nearby movement disorder clinic had been following 31 Parkinson disease patients in the area, 17 of them higher functioning and the other 14 much lower functioning. In fact, of those 14, 10 of them were affected by severe freezing episodes with severe nighttime akinesia requiring assistance with bed mobility tasks, 1 was completely bedridden and the others with major fluctuations in motor performance. 13 of the 14 patients also had fluctuating cognitive functioning.

Erica Vitek, MOT, OTR, BCB-PMD, PRPC is the author and instructor of Neurologic Conditions and Pelvic Floor Rehab, a new course coming to Grand Rapids, MI and Philadelphia, PA. This post is the next in her series on creating a course about neurologic conditions and pelvic rehabilititation.

Being a clinician, as we evaluate and treat people with pelvic health conditions, we typically take all systems of the body into account. We take the problem presented to us by the client and we examine, from all angles, how we might go about advice and treatment to best achieve their goals in alleviating the problem. We do a full review of medical history and pharmacology. We examine our client in-depth from a musculoskeletal perspective. We look at psychological contributions to the problem they are facing. We can look at their lifestyle and have them make a detailed diary to help us analyze their bladder, bowel, fluid intake and dietary habits. Do we also always include a look at the neurological components? Do we know what we are looking for? What are the best tools we can have in our toolbox as clinicians to look at our client’s problem through a “neuro brain”?

In writing each lecture of this course, I have had to step back each time I am developing a new concept and look at it with in-depth thought and contemplation about how I will use this in the clinic to assess my client’s concerns using a neuro-based approach. Taking the concepts and facts about the musculoskeletal system that we know well and then taking a look at the neurological systems contributions and relationship to that dysfunction can be challenging. The main reason for this challenge is that neuro system dysfunction is many times hard explain, presents with inconsistent or changing symptoms, may have motor or sensory deficits together or by themselves, may radiate to different locations than where the true dysfunction is located, and may have developed into central sensitization causing a hypervigilance to typically non-painful stimuli.

Neurophysiology is a dynamic and highly complex system of neurological connections and interactions that allow for bodily performance. When all of those connections are working correctly, our bodies can function at optimal levels. When there is a break or injury to those connections, dysfunction results but amazingly in some circumstances, our bodies have work arounds to allow for certain functions to continue working.

If we take the sexual neural control system of the male, for instance, a perfect example of this can be described. Many men were injured fighting in World War II. During their time in battle, many experienced spinal cord injuries. Some of these injuries were severe resulting in complete spinal cord damage at level of injury. A physician, Herbert Talbot, in 1949, documented his examination of 200 men with paraplegia. Two thirds of the men were surprisingly able to achieve erections and some were able to experience vaginal penetration and orgasm. Much of their basic functionality had been lost however amazingly there was preservation of erectile function.

The reason these men with paraplegia were able to maintain erectile or orgasm functionality is due to the physiological function in the sacral spinal cord. A reflex arc is present in this region. The definition of a reflex arc is a nerve pathway that has a reflexive action involving sensory input from a peripheral somatic or autonomic nerve synapsing to a relay neuron or interneuron in the sacral cord segment then synapsing to a motor nerve for output to the muscular region. These messages do not need to travel up the spinal cord to the brain in order to be activated. Instead they work within a ‘loop’ at the sacral spinal cord level. In the case of spinal cord injury, erectile function as well as other functions controlled by reflex arcs, can be preserved.