Volume 30 Number 1

Introduction

The management of incontinence requires a multiprofessional approach that includes doctors, physiotherapists, nurses and other health professionals.¹ Occupational therapy is one of the 'others' and has a valuable role, frequently misunderstood, underutilised or 'hidden'.²

Occupational therapists use person-centred and holistic approaches, based on a bio-psycho-social model of health with a goal to maximise independence and quality of life across the lifespan. The term 'occupation' refers to the things that people have to do, need to do and want to do to make life meaningful.³ Occupations can be categorised as work or productivity, leisure or play, and activities of daily living, including self-care. Toileting is an activity of daily living task, which is core to occupational therapy practice. The occupational therapy practice framework³ expands on this and describes the activity of toileting to include the following: “obtaining and using toileting supplies, managing clothing, maintaining toileting position, transferring to and from toileting position, cleaning body, caring for menstrual and continence needs (including catheter, colostomy, and suppository management), maintaining intentional control of bowel movements and urination and, if necessary, using equipment or agents for bladder control”.³

Occupational therapists assist people when their 'occupation' is impacted by disability, developmental delay, illness, accidental injury, ageing, or end of life. Not only is continence inextricably linked to independence in activities of daily living, continence and good bowel and bladder health impact all elements of occupation and independent functioning. Using the model of human occupation, the focus is not on the disease or diagnosis, but rather on the interaction of the individual with the environment, volition and self-efficacy.⁴

As with other health professions, bowel and bladder health is an area of special interest and high specialisation, so not all occupational therapists will have developed skills in this area. Occupational therapists tend not to provide services based on a bio - medical category, but rather consider how continence contributes to overall function and independence. Because of this, occupational therapy is frequently provided as a component of the multidisciplinary team, and their role in incontinence is often inconspicuous. The goal of this paper is to provide an overview, with some examples, of how occupational therapists can assist in the assessment and management of continence across the lifespan, from birth to death.

Key areas across the lifespan where an OT can assist in continence management

Children

There is a myriad of reasons why children present with incontinence, hence the team approach can be broad, including medical specialists, continence nurses, dieticians, psychologists, and physiotherapists. The strength of the approach is that the occupational therapist rarely works in isolation. Some areas where an occupational therapist can assist in children are encopresis or retentive fecal incontinence and enuresis, including bed wetting.  It is estimated that as many as 32% of children may have gastrointestinal disorders which can have a negative impact on the social, emotional and educational function of the child.⁵ By school age about 10% of children experience urinary and fecal incontinence.⁶ Children with attention deficit disorder and autism may have sensory processing issues which can lead to a fear of toileting, constipation, and retentive fecal incontinence.^5,7 Enuresis may present in children as bed wetting, associated with developmental delay and hyperactivity disorders.⁸ Incontinence is also present in some children with congenital conditions, such as cerebral palsy and spina bifida.^6,9 These are just some examples of where a child experiencing continence issues may be referred to occupational therapy for assessment and intervention as a part of a care package.

Occupational therapists are skilled in the assessment and management of childhood development and use play as a treatment modality. A comprehensive assessment of a child by a paediatric occupational therapist can assist in the development of behaviour management programs that may improve toileting problems.⁷ Breaking down the task of toileting is also useful in developing targeted strategies to improve independence. For example an occupational analysis of toileting identifies numerous sequential steps including mobilising to the toilet, transferring onto the toilet, managing clothing, manipulating pads, paper etc, flushing and washing hands.⁹ Difficulties in any of these steps can compromise continence. As a part of a co-ordinated team approach, the occupational therapist may work with physiotherapists to develop programs that improve pelvic floor muscle coordination and activation, provide education to parents and children on the anatomy and physiology of the digestive system, teach strategies for emotional regulation, and develop functional training plans for the bathroom, including hygiene. A combined physiotherapy and occupational therapy approach has been successful in assisting children to achieve full continence.⁵ Occupational therapists are practical problem solvers and functional training breaks down the tasks into sequential steps to enable a child to understand a complex task that can overwhelm.⁹ Children with sensory processing difficulties have a range of behavioural manifestations and managing toileting enables integration into schools and reduces parental stress. Occupational therapists have a large presence in childhood settings and may address continence issues identified in schools when other developmental or behavioural issues may also be identified.

Adults

Incontinence presents along with neurological conditions, such as spinal cord injuries, multiple sclerosis, Parkinson’s disease and stroke.^10-12 Occupational therapists and physiotherapists work in unity to ensure that gains in musculoskeletal and mobility are reinforced through meaningful activity.

A spinal cord injury may impact on bowel and bladder function, with 32% of spinal cord patients experiencing an impact on bowels and 44% experiencing bladder dysfunction attributable to a spinal cord lesion.¹¹ An integral part of the rehabilitation program for patients is mastering the tasks that support bowel and bladder management. This includes transfer ability, mobility, balance, arm strength, manual dexterity and mental health factors, such as motivation and depression.¹³ Occupational therapists have studies in the behavioural sciences and are trained in motivational counselling, cognitive behaviour therapy and use occupation to support good mental health and recovery.¹⁴ Other areas where occupational therapists can assist is in recommending adaptive equipment and home modifications.¹³ For example, the height, location and design of the toilet may require modification. Urinals and bed aids may be prescribed by an occupational therapist. Being able to clean and wipe properly is an important part of an occupational therapy assessment of bowel and bladder management and a variety of assistive devices are available. Assessment of function and knowledge of aids for independent living are core to occupational therapy practice.³

Support for managing continence may be available under the Australian National Insurance Disability Scheme (NDIS). Health supports such as pads, bed protectors, bottles, and collection bags (for example) can be funded if required in an eligible applicant's NDIS personal plan.¹⁵ Did you know that occupational therapists are approved prescribers for a variety of medical aids and equipment, including continence aids in Australia under the NDIS, Department of Veterans Affairs, health insurance schemes and jurisdictional medical aids schemes? This is particularly useful in rural and remote areas where the presence of health professionals may be scarce.

Older people

Incontinence is a risk factor for falls¹⁶ and pressure injuries¹⁷ and it is associated with cognitive decline.¹⁶ Along with falls and dementia, incontinence is a major contributor to carer burden and a precursor to nursing home placement. Aged care assessment teams include occupational therapists who are approved prescribers of activities of daily living and continence aids under My Aged Care in Australia.¹⁸

Prescription of aids, such as a bedside commode or night lights, may assist in restorative and rehabilitation goals. Simple home modifications such as grab rails may reduce risk of falls in situations of urinary urgency. Bidets have been shown to reduce the caregiver burden with older people.¹⁹ While not treating incontinence, the goal is to manage it, reduce the burden of care, and support people to live independently and safely in the community for as long as is practical.

As continence is viewed as intimate and personal, an assessment of daily living by an occupational therapist may identify the presence of incontinence as a part of the occupational assessment.²⁰ An important component of occupational therapy practice is client and carer education. As a primary health contact, the occupational therapist is in a unique situation to refer to other services once a continence issue has been disclosed.

End of life

Toileting is a primal self-care activity and linked to personal dignity and self-efficacy.²¹ Urinary incontinence is also a predictor of decline in activities of daily living.²² Assisting individuals to participate in self-care activities in the dying phase leads to quality of life at the end of life.^23,24 Managing continence, including aids is one way the dying patient can exercise some control or volition from an occupational perspective.^4,23 Many of the strategies listed across the lifespan can be employed in the palliative phase to support the client to maintain personal dignity.

How an Occupational Therapist can help

In summary, an occupational therapist can assist in the management of incontinence in the following key areas:

1. Assessment and planning
2. Equipment and medical aids
3. Home modifications
4. Client and carer education and training
5. Community independence

All the above have a focus on managing incontinence and improving quality of life by using practical, client centred approaches. Occupational therapists have a holistic perspective and consider toileting, including continence management as a fundamental human occupation. While the above discussion is not extensive, it provides some examples of how occupational therapists can contribute to the health care team.

Conflict of interest

The author declares no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author(s)

Susan Brandis
Occupational Therapy Department, Bond University,
Queensland Australia
Orcid - 0000-0003-2613-4114
Email sbrandis@bond.edu.au

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