Parkinsons + Pelvic Health

• OT Pioneers: Intro to Pelvic Floor Therapy  opens January 15-19, 2024
• We'd love to welcome you to Pelvic OTPs United - Lindsey's off social media community ($39 a month with no obligation!)

Meet my guest: Erica Vitek, MOT, OTR, BCB-PMD, PRPC

Erica has been an occupational therapist at Aurora Health Care at Aurora Sinai Medical Center in downtown Milwaukee, Wisconsin for over 20 years. Erica is Board Certified in Biofeedback for Pelvic Muscle Dysfunction (BCB-PMD), Board Certified Pelvic Rehabilitation Practitioner (PRPC) through Herman and Wallace Pelvic Rehabilitation Institute, LSVT BIG and PWR! (Parkinson’s Wellness Recovery) certified.  She has a special interest in Parkinson disease, for both optimal exercise rehabilitation strategies and treatment of Parkinson’s specific pelvic health conditions. She is faculty at the Herman and Wallace Pelvic Rehabilitation Institute and has authored the 2-day virtual course Parkinson disease and pelvic rehabilitation. 

Erica has been  been married for over 21 years and has two teenage daughters!

You can check out Erica's course on Herman + Wallace here. 

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Transcript

Lindsey Vestal I am incredibly delighted to introduce you to Erika Vitek. Now, I met Erika back in 2021 when we had the honor for her to speak about Parkinson's and the role of a pelvic floor therapist with neuro clients at our first virtual OTs and Pelvic health summits. Erika recently joined us on the Pelvic Atp's United Community. That's my off social media, very intimate community where we roll up our sleeves and it's an incredibly interactive conversation. Erika joined us to speak about our role in Parkinson's. And I got to tell you, I was blown away. It's not an area that I have a lot of exposure to or any experience. And so Erika came in and absolutely blew us away with the breadth and width of her knowledge. In fact, at some point in our interview, I talk about wanting to reinvent myself and specializing with Parkinson's clients because it is incredibly rewarding. So I can't wait to share the conversation with you today. Again, it's an excerpt from Pelvic Tpz United. So in case it seems a little out of context or you hear some other people asking questions. It is a recording from a conversation we just had on my private community. If you're interested in joining us, we would be delighted to welcome you. We have dedicated forums geared towards specific diagnoses, specific communities. It is incredibly organized. We also cover business topics because my husband, Doug Vestal, who supports people in starting their own private pay businesses, joins us to answer questions about starting private practices. It is incredibly rich and so much fun. So you'll find information on how to join us in the show notes. It's $39 a month. We go live for Tuesdays, a month together, and there's no obligation. Without further ado, I want to share a little bit about Erika. She's been an attorney at Aurora Health Care at Aurora Sinai Medical Center in downtown Milwaukee for over 20 years. Erika is board certified in biofeedback for pelvic muscle dysfunction, board certified pelvic rehab practitioner through Herman and Wallace LSVT BIG and PWR certified. She has a special interest in Parkinson's disease for both optimal rehab strategies and treatment of Parkinson's specific pelvic health conditions. She is a faculty at Herman and Wallace Pelvic Rehab Institute and has authored the two day virtual course Parkinson's Disease and Pelvic Rehab. Fun fact is, she's been married for over 21 years and has two teenage daughters. All right. Let's get into today's talk. 

Intro New and seasoned OTs are finding their calling in Pelvic health. After all, what's more ADL than sex, peeing and poop? But here's the question What does it take to become a successful, fulfilled and thriving oat in pelvic health? How do you go from beginner to seasons and everything in between? Those are the questions and this podcast will give you the answers. We are inspired OTs. We are out of the box OTs. We are Pelvic health OTs. I'm your host Lindsey Vestal and welcome to the OTs and Pelvic health Podcast. 

Lindsey Vestal Erica. Feel free to unmute yourself. Welcome. I'm so excited to have you here, everyone else joining us as this may be. So this is our first time meeting on our new platform, which is incredibly exciting. So we're all kind of learning our screen and where everything is. Feel free to unmute yourself. This is an extremely casual, comfortable, relaxed conversation. It's one of my favorite things about being offline and being able to collect dust in this really intimate way. So feel free to unmute yourself. Show, show your face if you're in a place where you feel comfortable doing so. Because this is going to be super relaxed and really, really exciting because I'm so honored to have Erika here. Erika, I am going to just briefly introduce you for anyone that may not know you as well as I do. I had the pleasure of meeting you first at our 2022 summit, Autism Pelvic health Virtual Summit, where you spoke around neuro and Pelvic health, which just blew me away. So that was wonderful. I'm so happy to continue this conversation today. So I shared this video earlier, but I'm just going to read through it now. Erica, you graduated with your master's in O.T. in 2002. You currently work for Aurora in Milwaukee, Wisconsin. And Erica specializes in female, male and pediatric avowal and treatment of the pelvic floor and related bladder, bowel and sexual health issues. You are board certified in pelvic muscle dysfunction, and you're a certified PRP practitioner through Herman and Wallace, who you are also on faculty for. And I saw recently you have some courses on Med Bridge, which is fantastic. So you have also attended extensive post-grad rehab education in Parkinson's disease and exercise. You're certified in El SBT, which is Leigh Silverman big, and you're a trained PR w Parkinson's wellness recovery provider, focusing on intensive amplitude and neuroplasticity based exercise program for people with Parkinson's. We are so thrilled to have you here today. You have taken a special interest really in all things pelvic health and for people specifically with Parkinson's disease. And it is such an underserved population and I'm excited to understand our role in it a little bit more today. So thank you for being here. 

Erica Vitek Yeah, absolutely. Lindsey Thanks for having me. And I know I don't have a serene background like you do, but it's all good. 

Lindsey Vestal Although we actually got lucky because your schedule kind of opened up and shifted today. So we're just so happy that you're here. And background background is unimportant. 

Erica Vitek Yeah. Yeah. Good. Good. Yes. Thank you. Thank you so much for having me. I do have a huge passion for people that have Parkinson's disease and obviously Pelvic health has been a big passion of mine. So I've been in this area for well, I've been doing Pelvic health since 2005, but I've been treating Parkinson's since 2002 and we were a center of excellence when I started working here and I wanted to do Pelvic health. But everybody's like, We need you to see people with Parkinson's. And I was like, I don't know what I'm doing. But yeah, I've learned to love it and I've learned so much about it and I've combined my two loves for sure, so I can't wait to tell you more about it. 

Lindsey Vestal That's a dream. That's a dream. I love that. And that's love. The area of the country that you're in. So I'd love to kick it off. I know we've got some people that have questions because the the message board has been lighting up with that. But if you don't mind, especially for those of us who are still really learning more about our role, maybe just kind of kick it off with a general question regarding like what the role of an occupational therapy practitioner is in supporting clients with Parkinson's with their Pelvic health Yeah. 

Erica Vitek You know, I think the most important thing to think about with people that have Parkinson's and Pelvic health is their movement disorder specialist neurologists, which are very hard to find around the country. There's very few of them. They don't see them for more than, say, 30 minutes, maybe 45, maybe an hour, if you're lucky, every maybe six months, maybe a year, maybe in between. You see like the nurse practitioner or the physician assistant in the neurology office. And so you really don't see your Parkinson's physician very often. And so the role that we can even just play as clinicians in general, as we know in other populations too, is like we get the time, we can put in a little bit more energy to dig in, and it's really nice to be able to have that time with someone that has a chronic disease, progressive disease, where we can kind of dig in more to these symptoms, the non-motor type symptoms we call them in Parkinson's of bladder, bowel, sexual health, sleep issues, depression, anxiety, apathy, all of these other like non-motor type symptoms that don't affect as far as like their walking or the stiffness in their muscles, the tremor that they might have. Experience. Those symptoms in the Non-motor category aren't always brought up at these appointments because the physician can treat the motor symptoms with pharmaceuticals. The non-motor symptoms, yes, some of them can be treated with pharmaceuticals, but obviously a lot of people do like to try to treat these things more conservatively. There's a lot of issues as we get older with taking more and more medication, as we all know. And the combination of taking Parkinson's movement type medication to replace dopamine can have effects on taking some of these other medications. So we just know the dangers of just piling on medications for for things that we maybe could help much more conservatively. So I really feel like we just have such a huge role to help the quality of life aspect. And I mean, this goes for any pelvic patients that we see. As we know, we always talk about how much we can change people's quality of life. But so important for somebody that can't make it to the bathroom in time because they can't move things like that. 

Lindsey Vestal So yeah, and what really struck me about what you said, Erica, is that the number one physicians don't have the time, which which we definitely know. But then when they do in terms of those non-motor issues, bowel, bladder, everything that's pelvic health, they're not looking at it in this holistic way that perhaps us as pelvic rehab providers do. They're like you said, thinking about stacking on the medications and not really talking about roles, habits and routines and all the behavioral strategies. So there's a strong need here for us. That's incredible. 

Erica Vitek Yeah, it really is. And you know, the interesting thing is, even though the physicians around here know me quite well, I work with their patients and exercise therapy, I actually get most of my referrals after seeing someone for exercise therapy. And then I remind them or tell them that I do this and they're like, the physician might have mentioned that. Or, or no, no one's told me about this yet. So I think actually there is so much more room for growth. I'm not really sure why the referrals don't just pour in because everybody has these issues. But either way, I have a great opportunity, at least in my clinic, that my referral source mainly does come from my patients who see me for exercise their be for SVT bag. I have a very robust program of that here at my clinic and then a lot of them filter in from that. And it might even be just like they go to the bathroom a lot during my session or they struggle with constipation and they're just not feeling the great us and things like that. But also just another thing to even keeping in mind is the medications for motor symptoms actually don't work that great if their digestive system isn't working well. So I can go into that a little bit more too, if anybody's interested in that aspect of things. But we can play a huge role in helping their medication work better for their Parkinson's motor symptoms if their God is moving better. 

Lindsey Vestal I would love to hear about that. Is there anyone else on? Please unmute yourself. We want to go in that direction. Yes, totally. Would love to know more about that. 

Erica Vitek Okay. Awesome. Awesome. Yeah. So I obviously go into great detail on this in my course, but I have that through Herman and Wallace. But in brief, and just so we have a really good kind of level understanding of it. What happens is when someone takes dopamine replacement therapy, which is the carbidopa leave it over. That's kind of the gold standard medication for people with Parkinson's. Cinema is the like the brand name, but Carbonneau believe it, Ova is kind of that generic name. It's been the gold standard treatment for people with Parkinson's since the 60s. There has not been a better drug since the 1960s than carpet or believe it. So it's it's shocking. There are enhancement drugs to make things even easier to move. But there has been nothing as gold standard and as promising and as effective as carbon. I'll believe it over. So when an individual takes kava, don't believe it or they'll leave it up. It is actually like a precursor to dopamine. Dopamine cannot cross the blood brain barrier without breaking or it causes side effects. If you just take straight old dopamine, you wouldn't be able to function it. You'd have all these peripheral side effects. And so you take carbidopa leave it all. But when the leave a dope gets into your stomach, some of it does want to convert to dopamine. And so the carbidopa takes the edge off of some of those side effects such as like nausea, sense of just like unease and things like that. And so then that leave it all but has to then make it into the beginning of the small intestine and in the duodenum that is where the medication gets absorbed and gets into the bloodstream and then can get to the brain and then crosses the blood brain barrier and then can go through a process of converting to dopamine. So it's a huge long process. We actually go through that whole process in my course and how that all is affected. So if someone's if someone's small intestine and large intestine are mobilizing anything and you have gastroparesis, which is another symptom of Parkinson's disease, then those medications aren't getting to where they need to be to help their movement symptoms. And so we have kind of this compounding issue that can happen is a huge struggle for people. And when, you know, really in the perfect process only about they say like somewhere in the 40 to 50% range of dopamine actually gets to the brain even with the regular process. So now if it's delayed even further and the stomach acids and things that are happening gastric wise, break this down more, they get even less to the brain. So we can be super impactful here. 

Lindsey Vestal So can you tell us like, I know this is tricky, but can you tell us like some of the things you would do with a client like this to help with that? 

Erica Vitek Absolutely. So the the trickiest part, I guess, is the gastroparesis, because I mean, that that's something that really they don't tend to give medication for because of all the other side effects that come along with that. So I don't often see someone on medication for Gastroparesis, but a lot of times physicians will prescribe like either a low fiber diet so that like easy digestion and or spacing out smaller meals throughout the day to allow for the stomach to be emptying a little bit more frequently. So that can definitely help. Some people might even have to do something like a crushed their medication so it can kind of get a kickstart when it gets into the the GI system or take their medicine with like a carbonated beverage or something like that. But physicians are real good at knowing whether someone needs some of those booster factors. And then for our role, definitely working on all of the things that we can do with motility. What what are the kind of things that you and I can do for motility? So working on mobilize mobilization of the gut via abdominal massage. So obviously that's probably one of our most common ones that we might recommend. I use cupping a lot on the belly and to just try to follow that pattern of the large intestine and or even facilitating just around the umbilicus for small intestine movement. I do use Trans and IFC, so I use a lot of electrical kind of stim type interventions for these individuals to kind of neural modulator kind of give a little kickstart to the system. I use a lot of biofeedback to obviously help with the exit. So in Parkinson's, the bowel system is super challenging. So they have a number of things going on. So, you know, this list is is so extensive. I let me let me kind of start from sort of from the diet lifestyle aspect. Now that I've just on that little summary, I'll just pull up. So as far as diet and lifestyle, a lot of people with Parkinson's don't intake a lot of food because they may have a deficit in swallowing. They may have like a modified diet because of that. They as we get older in general, like liquid intake isn't as good, but it also could be affected by their swallowing too. A lot of coughing or choking or maybe they're on thickened liquids or things like that. So there could be a whole variety of things going on with dietary reduced physical activity, renal increases, constipation as well. Right? So encouraging activity and exercise, which is my other role here in the clinic, is so huge for this as well in just getting people moving and exercise we know also is possibly the only thing right now that can slow Parkinson's. So there is the idea is really like intensive exercise right now that they're thinking can have a positive effect on slowing the disease. We don't have anything that can stop the progression, but we do believe that it can slow or even we can restore function, which is amazing. It's not just a compensatory kind of thing for them. And so those are kind of that that lifestyle piece that we can have a role in as well. Then the Parkinson's meds themselves are anticholinergic based and so we know what that does to our system slows us down too, right? So we're trying to take something to move better and now the gut's not getting it to where it needs to be to be absorbed and that it's slowing it down even more. So that's a big challenge. We also have just generally the enteric nervous system, so the autonomic and enteric nervous systems can be affected. And Parkinson's, Parkinson's is mostly is thought of when people think about it is in the brain that there is this degeneration of the dopamine producing cells in the brain, but there's also this gut relationship. So they feel that there's actually this the Brock theory, if anyone's ever heard of that, it's be our AK. His theory is that it's kind of a traveling disease and that it starts kind of in the brainstem and it travels into the like the midbrain, which is where the dopamine cells break down and then it travels throughout the rest of the brain and causes cognitive deficits on these other deficits. But there's also this vagus nerve connection to the gut thing that like, does it start in the gut or does it start in the brain and did the travel to the gut or what what is that process? So there's a lot of theories on all of that that I also go into in great detail. But in brief, there is the thought that either maybe it starts in the gut and travels to the brain or it starts in the brain, travels to the gut. And so there's something called Parkinson's is also called like a synuclein apathy. So it's not just a progressive neurologic degeneration, but it's a synuclein apathy, meaning it they get these clumps of alpha synuclein that are dysfunctional in their protein that all of us have in our body, but they go into clumps. This is like Alzheimer's and like the Tao and the other proteins that happen in Alzheimer's where they come up. But in Parkinson's it's alpha synuclein. And so these deposits, they deposit themselves into the colon or into the brain, and that's what causes, they believe, the dysfunction to happen. And so now the enteric nervous system itself has these dysfunctional cells. They're not sure if they necessarily like kill off these cells. They don't suspect that actually it just makes them dysfunctional. They're still there, but now they're dysfunctional and they're not mobilizing the gut as maybe they they did before. So there there's all of that. And then people with Parkinson's, as we've been talking, have kind of this skeletal muscle problem with movements. They can't move as well. And that goes for the abdominal activation. So we have to be able to create some sort of abdominal strain type pressure, proper pressure to have adequate defecation. And people with Parkinson's do not create that same pressure. Then the rectum doesn't contract as well. So now we have inadequate rectal contraction and then that's compounded by a potentially dishonor objectification. So it's very complicated by so many things. It's literally from mouth to anus and people with Parkinson's, there could be dysfunction going on for a whole variety of reasons. So we can just play a role in all of that, especially the muscular, the muscular piece. But understanding the pathophysiology behind it can be so helpful clinically. I'm big on the physiology. I love to understand the why and when my patients hear about the why, it's like a relief to them because it's like, my gosh, I got it now. Now we can actually facilitate the right areas, the right things to to enhance my function. Maybe we can't make it perfect, but we can improve the quality of life and focus on the right areas that are just functional. That was a really long answer. Lindsey. Sorry, I like about this. Like always. 

Lindsey Vestal I want you to I love that you're speaking our language here in this community because it was so fascinating. I'm like, now I'm like a lawyer. I want to reinvent my. Now, if I want to specialize in helping people with Parkinson's, this is like it's like the marriage of all the things that I'm so passionate about. Vagus, nerve, gut motility. Like all I've got, I've got, you know, elimination, everything. Yeah. I want to just. I have a thousand questions for Erika. I want to open up the floor. I want to see if there is anything on anyone's mind that they would like to ask her. 

Questioner 1 I don't have my camera on. Sorry. So I'm very intrigued about kind of the nutritional aspects because one, the research is like saying that they should participate in a lot of exercise, although they're not getting adequate nutrition to kind of fuel their bodies in a way for this exercise. So is there like I know you mentioned like low fiber, but is it like recommended I do a lot of research on like high protein diets. So is there anything about eating a high protein diet to kind of allow them to participate in this vigorous exercise program? 

Erica Vitek Outstanding question. Protein is the enemy of Parkinson's. Yeah. So it's a huge issue because carbon, I believe it. Alba and protein compete for the same uptake in the stomach. So if someone eats high protein and takes their medication, their medication as the disease progresses will not work. So they can eat protein on a schedule that's not near their medication, like for example, in our say, separating when usually so like an hour after they've taken their medication because it's already hopefully been through. Now that depends on their speed of gastric emptying or like two hours before maybe. So it's it's pretty tough. Most physicians recommend eating protein in the evening when movement will not matter as much for nighttime. So most people have to eat a high carb diet around their medication because of this problem. So I yeah, it's very, very tricky. The intensity of the exercise and it varies throughout. Therapists, you know, their training and such, the intensity that I work on is somewhat aerobic capacity, but more toward amplitude. So it's really training, size of movement, trying to get someone out of a hyperkinetic or o'brady kinetic state and feeling their body actually can do it. They just don't realize their sensory motor system is not matched up. It's not calibrated. So they may actually feel like they're moving big enough that their steps are big, that their arms are swinging, that they're fluid, but their body, to our observation or even to family or spouse observation is not normal. And so unless T-Bag drives that up to normal, so the intensity in that isn't so much the muscular building, although strength training is recommended and high intensity training like aerobics, 60 to 80%, your heart rate, max is also recommended at that 150 minutes a week that they recommend for most people right now. So yeah, I mean, that is a little bit of an issue that, you know, really good issue. You bring up the diet that's actually recommended most is the Mediterranean diet because Parkinson's is thought to be inflammatory and possibly causing this alpha synuclein to clump. You know, there's so many unknowns still. There's a lot of things going on in Parkinson's research right now. There's a genetic component. There's environmental components, so many things. But the anti-inflammatory diets are one of the things that they definitely encourage. The Michael J. Fox Foundation has an excellent diet guide that they have. Davis Phinney Ah, excuse me. It was the Brian Brian Grant Foundation. He was a professional basketball player. He is really into diet as well. So there's a lot of like diet guides out there for people with Parkinson's as well that help with kind of shaping really healthy diet around someone's needs. I hope that helped. 

Lindsey Vestal That was awesome. That was awesome. 

Questioner 2 Yeah. And after this and probably enough to put my video back off because I'm going to go get a little one at daycare right now. But thank you so much. So I think first I just wanted to say I'm so excited about this topic. It was I'm currently in my last my capstone semester of my OTD , so I'm not yet at 40. And yes, I'm so excited. But what brought me to O.T. for a couple of things that really Parkinson's and pelvic floor and I knew they I knew this. Was coming. So I'm so excited to hear this, that this is this marriage. Like Lindsey just said, I was on the board of directors as the vice president for the Hawaii Parkinson Association when we were stationed there up until 2020. So it is near and dear to my heart. I'm still very much in touch with them. I would love to let them know about you because I think virtually it would be some great resources that they could tap into and understand. But I really like the idea of like the way the Gap plays into this. And I just I wanted to know. So do you do you do it set? Like, do you do the pelvic floor? It sounded like you did. I was driving when you said it outside of Stu. You do your pelvic floor therapy, okay? And that's where you were saying, like, the cupping and other mobilizations and things. 

Erica Vitek Yeah, those were just some ideas. Ideas that I was throwing out there. Yeah. Ls50 is a protocol. So it's 16 visits. Yes. Yeah. 

Questioner 2 Yeah, we hosted it. We hosted actually, we hosted Alex out there to get more therapist because in Hawaii there's a big gap of what, you know, what is the need out there? My goodness. And my other question was, do you I know you said get most of your referrals because like the neurologist or somebody has already sent so and so to the Alice V t portion of your therapy. Do you ever go to Parkinson's groups or anything like that too? Okay. So you do like smiles. 

Erica Vitek All the time. Okay. I have a positive. 

Questioner 2 Response to this. 

Erica Vitek Obviously. Yeah. Usually the patient response is outstanding. That is really where I do get most of my referrals, either from someone that seeing me for exercise therapy or they've seen me speak a like a group or someone tells their friend they heard about me at a group and then they come and see me that way. So I speak on probably, I don't know. 4 to 5 groups a year probably on this topic and or else VCE which then people know that I do this or that. It leads in to that because people want to talk about it. I spoke I have spoken virtually at support groups as well. I spoke at a California support group like a couple of weeks ago, and I just spoke to a group in Oklahoma last week. So, I mean, I get requests because of what his specialty area. So I'd be happy if you want to connect with you here. Lindsey has my contact information and I'd be happy to share that. I'm happy to do those kind of things. 

Questioner 2 I really near and I'll share that the president who recruited me, I was a yoga therapist, so I actually started a whole yoga program for the Hawaii Parkinson Association and did stuff there. And but the President has recently passed away. He was a dear friend and probably from other not not Parkinson necessarily related. I mean, that's always hard to tease out. But he was young, he was an effective. But the new president was a young onset diagnosis and he is like exercise all the way Jimmy Choi type of follower. Like we've had Jimmy Choi on for all the symposiums and stuff out there. Yeah. So big. Lots of great stuff. So he would just his name is Glenn. He would love to talk to you and invite you to stuff. So I will. I'll let you know. So thank you so much. I'm going to stay on, but just take off video. So sorry. 

Erica Vitek No problem. Can I follow up on your yoga? Because I so I cannot take credit for this. And I'm not a yoga instructor, but I learned a yoga routine for constipation through the Parkinson Disease Foundation. It is outstanding. I teach it at my course. Now I give credit to the person that taught me, but I love it and my patients love it. I've done it at symposiums. I've done it with patients in the clinic. I've done it virtually with clients. Love it, absolutely love it. So I just wanted to throw that out there too. 

Questioner 2 Yeah. Fantastic. That's awesome to hear. Yeah. Okay. Well, I will let Lindsey know and we'll we'll get more information out there. 

Erica Vitek Only we can get excited about. Constipation. Yoga. 

Questioner 2 Right. I know. 

Lindsey Vestal You know you found your people when I. 

Questioner 2 Love that. 

Lindsey Vestal I love Lindsey. I'll definitely introduce you to Erica since she said she's happy to have for me to connect you guys. So I'll make sure to do that after today's call. 

Questioner 2 Okay? Perfect. Okay. 

Lindsey Vestal Anyone else have any other questions for Erika? All right, well, I've got some, and that's okay. Anyone interrupt at any time? So I'd love to know if you don't mind a little bit about, like, the like illustrating the process a little bit more. So learn a little bit about maybe the evaluation, maybe like a sample, a sample treatment, you know, bite sizes, of course, and maybe like a typical home exercise program specifically for for the Pelvic health clients that you're seeing. 

Erica Vitek Sure. Sure. Yeah. I actually pulled up a patient that I thought would be so we talked to actually this workshop guide. We talked a lot about bowel. I do see a lot of patients, but I also see a lot of bladder. That's the one thing we haven't touched on. And sexual health obviously too. But yeah, so let, let me first talk about the evil process and then I can tell you about a bladder client that I'm currently working with and doing some things about. So, so the evaluation itself is that it's really not that different than your other public health clients, right? We're looking at the same stuff, but we're looking through the our neuro glasses are the eyes of a neural therapist. And so I always kind of want to know, you know, when was someone diagnosed, how long have they had Parkinson's? Are they on the carpet or believe it or on medication or are they kind of fresh, brand new? They are on the medication you had kind of where are they at with that? So though, I think those are some important factors because as the disease progresses, the tendency for bladder and bowel and sexual health issues to get worse is more common as well. As you know, your movement symptoms are getting worse. So your your ability to get to the bathroom is harder. Your relationship with your spouse changes maybe to caregiver roles and things like that. So there's a lot of like things that change as the disease is progressing. So it's really important to kind of get an idea. Now the other thing I do tend to want to know, and we asked this with our other clients too, is like, how long has this been going on? Because constipation is actually one of the number one prodromal symptoms of Parkinson's. So some people have had constipation for 20 years prior, may have thought it was just a general medical condition. But then come to find out they realize that they actually had some other like little symptoms that there like, you know what, I think I actually had Parkinson's way, way back. And now it's just manifesting itself into these additional symptoms. And so that can be a really important kind of thing to just understand and to know kind of where they're at with how long this these problems have been going on. The medications are very complicated with people with Parkinson's. And we kind of already talked about like the the protein effect and things like that and their timing the. Is is so particular. So usually the medication timing is every four hours, maybe six hours, but they sometimes take three to maybe sometimes six doses a day. It kind of depends on the person. And everybody's taking like a whole gamut of different things. And so understanding the timing of their medication can make all the difference in your evaluation and your follow up treatments and even your discharge. So if you're evaluating someone and they've just taken their meds like 45 minutes ago, they're probably what's considered an on time, meaning their medications are at peak effectiveness. Their movement probably is of their best quality, at least on this medication regimen. They're going to be able to follow cues probably a little bit better. Their muscular function is going to be a lot better. If there are three hours into the medication, their half life of that med and the washout period is already possibly happening. So their medications are going to be more in an off period. And so really important to know that, too, because if you're comparing initial to discharge, you probably want to do that around the same time. And that's the same for like my exercise therapies and stuff like that. So that can be really helpful. Your assessment is going to change dramatically because if you ask someone to squeeze their pelvic floor when they're off and they're their hands don't even really work that great or they're shuffling their feet or they're not walking great, or they're postures hunched over their pelvic floor contraction, it's skeletal muscle is going to be the same thing. We're going to have trouble assessing it. And what's great about our sweetie thing, just as an aside, is you retrain how to use the muscle even when you're off. And so I use a lot of principles of amplitude in my training of the pelvic floor. And so that can be super helpful in your assessment, like knowing how to cue, when to queue, what to queue can be helpful, but just kind of keeping that in mind, the medications, their current level of activity super important because that's going to help us know are they exercising, Do they have any are they taking in fiber? Are they are they have swallowing problems? Do we have to worry about like bloating and what's going on in their gut? So super important there. And we talked about the protein interaction. Do they have a support system? Really important because we know is progressive and chronic that do they need someone now? Do they not need someone? You know, how are these night times going that's kind of going to kind of be my next thing that I talk about is because their off time of their medication tends to be more at night because you have a longer period of time where you're not taking like another carbidopa leave it open to get a little dopamine in the system for movement. So you've got this time now where maybe your body isn't moving greatest and if you have urgency and now it's dark and now your feet don't move and all of that. So super important to ask about night time, fall, risk, fall history and how they move when their medications are at those lower lower levels. Can they get out of bed? Like those kind of functional things that we really care about? Can they adjust their clothing in the bathroom? Do they have adaptive equipment already? Do they need to consider adaptive equipment, condom catheters or urinal, commode, those kind of things and that? And then a lot of times I also take a huge consideration into like posture and the diaphragm because posture is typically high phonic and or sometimes even what's called Camp Kamiya, which is a foot almost a full flexion at the at the waist into almost like a 90 degree when it's very progressed when someone's an upright. But fabric would be the typical and we know what happens with the diaphragm when we're I can get that very narrow angle and our diaphragm changes how our pelvic floor works. And so that can be just an important thing to look at breaths, support for, even voicing. As we know, most people are hypotonic with Parkinson's and so that all of that, like voicing and breathing and everything just changes your pelvic floor. So keeping that in mind during your battle, just to understand that. And then I often right away, right off the bat, a ask for a bladder diary because I and I with measurements, I'm very big on measured bladder diaries and I really investigate the nighttime stuff. That's usually an issue for almost every single person with Parkinson's I work with is a high frequency voice at nighttime and typically high frequency voice during the day. So I have a bladder scanner in my clinic to just to check are we having any like retention? Is there anything going on? A lot of my patients that have Parkinson's have never seen a urologist. Now, males more likely because the prostate exam sometimes if the general practitioner to do one or doesn't feel feel confident in that area or there was a noted enlargement or something. So my men probably have seen urology more my ladies not usually, they usually have not seen urology. You're old guy and and they're like, Wow, I haven't seen one of those in a while. So. So a lot of times we're like the first provider in a long time that has talked to them about this. They're neurologists just like, yeah, you could go see Erika. Sure. She talked to you about that. Okay. You go see her then for that. Or. Or they already. Yes. And Erica does that. You can go see her. So, yeah, I mean, a lot of times that is how they find me for that purpose. So the bladder piece, let's just briefly hit on that and I'm going to talk about a case I just wrote a few notes about a gentleman I'm seeing right now. So the bladder issue is that dopamine is plays a role. The basal ganglia where the dopamine lives in the brain plays a role in inhibition during storage. And so when we don't have enough dopamine, our bladder cannot be inhibited during storage, we just get random. Blatter urges at very low volumes. So the very typical presentation of someone with Parkinson's is like a voice. I mean, it's it's very difficult for them to manage their intake reduces because maybe swallowing or maybe they're just not to drink, they're not thirsty or because they're going to the bathroom literally all the time. I mean, you have 100 CCS in your bladder. You're going to be going a lot. So it's really, really hard to manage. That's just such a common thing. A lot of times some of my goals, like you ask Lindsey, Lindsey is like my goals are to even just shoot for like trying to get like 2 to 5300. That's why I love to have a measured bladder diary of something to go off of. We have something we can measure with, with techniques that we teach, with urge control, urge management, trying to calm our nervous system using other techniques because their nervous system is wonky and not working right. And so we can try to use the things that we know how to do to help them calm down. So I have a gentleman right now. He was referred to me by his geriatrician to ask me to beg because she suspected he had Parkinson's. And so he came to me for me to beg, even though he didn't have a diagnosis yet. And he very obviously had what I thought was going on. And then like a month after we finish, like he was officially diagnosed. So his his wife retired earlier in the year and she started noticing these things now that she was home more. And she's like, what's going on here? And so that's kind of how that all got started with the geriatrician. So what then happened was he started having this, like, rapid decline of his bladder that just like came on kind of out of nowhere, like his motor symptoms were progressing and now his bladder was progressing as well. And so his wife obviously was very concerned about this. She still wanted to be able to, like, go out and do things. She was finally retired. They could, like hang out and go places. And he started to not even been able to toilet himself in public. He couldn't figure it out. He was cognitively declining. Things were happening really, really fast. And at night he couldn't even place the urinal on his own. And during the day, even touching his penis, he would get such an he couldn't even hold it, even for touching his own penis. So she would act. She was like basically toileting him all day long. And this guy is mobile. He is functional. He is, you know, I mean, but his bladder was like out of control. It was crazy. And so we did when he when he finally came to see me, by the way, his bathroom and bedroom are upstairs because isn't that always what happens when you when you have some problem like this? Okay. So he had he got a urinalysis, which I was like, let's get out first. Let's just make sure nothing's going on. And he was negative for UTI. He saw the movement disorder specialist after he actually saw me for the evil for Pelvic health. So he was not yet on the carpet. I'll believe it. When I first evaluated him, his muscular control was not great at all for any muscle, so I knew that his pelvic floor was probably not doing anything. And so in the beginnings of our treatment, before, he was really on full dose of carbidopa leave it, although it was extremely hard to get him to activate his muscle like extremely difficult. So one of the things that I use a lot of is biofeedback. We can get some visual feedback and understanding. The tricky thing was even on biofeedback, he like could not activate. So I did a lot of digital stim. Like just like here is where you want to squeeze and then you have to give it time, about 3 to 4 seconds for someone with severe brain to finish up for them to actually activate their muscles. So in the average person might be only a second, but for someone with radiation Asia 3 to 4 seconds, you might have to wait for that initiation. So the cues might have to be slower. The session takes longer. You may need to just give them more time to just like let it kick in. Then when he went on medications, we all of a sudden just like had this, it was working. And it was just amazing. It was like my most obvious example and biofeedback of a pretty kinetic, a kinetic, hyperkinetic pelvic floor to a awesome pelvic floor responding to cues right on task, able to activate. And now just like a week. Or was that two weeks ago he was here and his wife's like we were at our friends for breakfast and he said I have to go to the bathroom. And I just held the urge. And he waited and was able to get there on time at a friend's house and go on his own. So and now he comes to my exercise class for LCT big. We kind of have a little graduate class and he goes to the bathroom on his own, which in the beginning he wasn't doing. So it's just amazing to see the progression and to see that we can restore this function. We don't have to let this stuff be like this. You can't you can't live like this. Nobody could. And especially when your muscles don't work right to walk as I keep bringing up as that's huge. But yeah, he's doing better all around walking and just everything just amazing. So I did do a bladder scan on him at. One point he had 45. So it wasn't anything to major that urology would be too concerned about. So yeah, that was that was kind of his his story overall, I did because of his mild cognitive impairment. Like another thing that I did with him was I do sometimes make like laminated signs for like the bathroom or for like by their the place they sit in the evening to enjoy their their evening. And that just gives like basic cues like, okay, when you feel the urge, squeeze your pelvic floor and hold. Stand up from the chair, walk to the bathroom like some basic things that I had to give him at the beginning. He doesn't need that anymore. But when his Parkinson's was not treated, he did need a lot of that. And then in the bathroom, I had like a sign for him, squeeze your pelvic floor, adjust your clothing, because he would always start peeing before he would get adjusted, adjust your clothing, then sit down on the toilet and urinate. And that helped him so much. It was just like the verbal or the visual reminder of like the commands that helped him so much. And a lot of times that sometimes what people with Parkinson's needs is different kind of cues. Sometimes a verbal cue can like reset their motor system, a visual cue, reading something and different ways of cueing. So for him, it was like sometimes if I said lift and squeeze, he could do it. Sometimes if I sometimes I said that he couldn't. And so then I would like switch it up and we'd use all kinds of different words, tighten clothes, whatever. I mean, just changing it up all the time and just by changing the cue helps find that different motor pathway to help him squeeze his muscle. So yeah, and then I used hands with him as well. So do you want me to go into that real quick? Lindsey? Is that okay if I just mention that? Sure. Okay. So just in brief, so with Chen's unit for Parkinson's and nighttime, not sure. Yeah. So he was getting up a lot during the middle of the night and needing that help that I was mentioning. So I use posture to be a nerve stem with some of the literature that's out there for Parkinson's. And for him, 30 minutes a night, his wife sets him up while they're hanging out watching TV. And if he doesn't use it, the nights are terrible. And when he does use it, the nights are wonderful. So it's really effective for him. Anxiety does have some impact on that, too, where if he is having a lot of anxiety about activities the next day, his bladder will be kind of bad at night. But the times really helps take the edge off of of that for him with Neuromodulation, ideally, I mean, there may be some placebo aspect to it. I mean, I guess we don't know that for sure, but I think placebo sleep, Why not? If it is hoping it's Neuromodulation. But hey, it's a little bit of both. Let's take it. So, thanks, Lindsey. 

Lindsey Vestal I love that. 

Questioner 3 Hello, everybody. First of all, I love what you just said about placebo. Like, if it works, it works. So I do love that takes to back to the question, I was wondering is you mentioned, like your residual or not your residual, I guess, but like the like volume for retention, do you find that most urologists are having like the same threshold for that? Or like, is it maybe like physician dependent or could it be like diagnosis dependent? I'm on a committee right now trying to develop like balance bladder protocols for our unit. And so. Right now, like the orders are always different volumes and so I'm just curious, like If that makes sense and like maybe like what a, like what volumes you would see of like, I'm not worried about this for retention versus like, this is a red flag like I do think this person this person who. 

Erica Vitek Yeah, I do think it's somewhat physician and. Diagnosis dependent. So I know that it makes it so hard. I think, you know what, I'm going to just to be 100% honest about my experience. As I've told Lindsey, my main this is my gag right here, Parkinson's. Okay. So I've seen only a few very few spinal cord fumes and a couple like hereditary like spasticity conditions that were pretty significant. So I haven't seen a vast amount of other neuro just because this is like my lane. Not that I won't see them. I just don't get those referrals for whatever reason. Although we're trying to expand neuro public health in general, so I may. But right now this is like my lane. But what I've, what I've seen is most of the urologists I work with, typically somewhere in that 50 to 100 range, they seem to be still okay with that. Anything over 100 seems extreme. But I, I think that when I have seen even likes with some of my general population, if I have someone that gets a lot of bladder infections, that 100 is not going to be good. I mean, that's not good. So I think I would lean toward 50 or less or yeah, I mean, I don't know if I if there's a straight answer on that. 

Lindsey Vestal Amazing. We are about out of time. We might be able to take one more question. But I do. Erica is joining us in the middle of her workday. So I know she probably has another client that she needs to get to. So does anyone have any last questions? 

Questioner 4 I have a quick question. Just I think it's so awesome, your subspecialty area, this little niche that you found. I'm just I'm new to Pelvic health and I'm really trying to find that marriage with the CI population. And I'm just curious if you have any suggestions of how you paved your way, how you got buy in from like the physicians or anyone else that you're working with.

Erica Vitek Yeah, the buying has been a little challenging because of like what I mentioned. There's so many other problems they talked to their neurologists about and I'm like, not top of the list. I wish I was, but I've created my own hand out. So that was kind of like one thing to kind of get in there and then going out to the groups. Of course, that has absolutely health is like getting getting the word out and then me contacting the physician after and saying, Here are the results. This is what this patient can now do. And that actually probably has built those relationships even further. I can't say that I my referrals are absolutely exploding. I can usually get the exercise refill first. To be honest, it's kind of crazy. But I think it's it's coming because patients are asking more about it because they know about me, they've heard about me and the patients are initiating it as far as like getting getting you to the next step too, with, with I mean for as far as like learning for for yourself and things like that. I mean, this is all everything that I've done is like self taught. I there is, there was nothing. I did everything on my own. I spent an entire career building my my knowledge. And then I took a whole year to write, you know, two day course because I was just like, I want to get this down on paper. I want to tell people about this. I want to help more people, and I can't help everybody. So I'm going to do it this way. So yeah, I it took a lot. I mean, a lot of my stuff was from research articles because there just is not a heck of a lot on neuro for us. Yeah. Yeah. 

Questioner 4 That's awesome. Thank you. I'm very much in that exploratory phase. I've worked with Spinal Cord for nine years, but I'm like, really delving into bowel and bladder especially and just trying to gain as much knowledge in both of those fields and figure out where they cross. So thank you so much. 

Erica Vitek That's awesome. And thank you for sharing your experience with the kind of the acute aspect of the bladder. I appreciated that. And Sarah too. That was great. 

Lindsey Vestal Erica, we are so grateful we could spend another couple hours with you. This has been amazing and we have such and such incredible respect for the journey you've been on and just the way you've been able to make this so accessible and absolutely fascinating. So we are so grateful for your time today. Thank you for joining us. 

Outro Thanks for listening to another episode of OTs and Pelvic health. If you haven't already, hop on to Facebook and join my group OTs for Pelvic health, where we have thousands of OTs at all stages of their Pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and posted to IG Facebook or wherever you post your stuff and be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic health podcast.