Physical therapy does a lot more than you might expect

If you thought that physical therapists only worked on muscle groups, you're missing a big part of the picture. Today's guest is Laura Keyser, a Doctor of Physical Therapy and Director of Clinical Strategy and Global Health for Axena Health. She explains how a PT can help you not just with exercises - though they're incredibly effective there - but also with diet, weight management, stress and so many of the other factors that can influence your incontinence symptoms.

The she shares with us about the Leva Pelvic Health System, which is a prescription device designed to help women strengthen their pelvic floor muscles. It's shown remarkable results for women with bladder leakage - nearly 75 percent of those who've tried it found significant reduction in their symptoms.

For more information about the Leva System, visit LevaTherapy.com.

To learn more about the National Association for Continence, click here, and be sure to follow us on Facebook, Instagram, Twitter and Pinterest.

Music:
Rainbows Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

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Transcript

The following transcript was generated electronically. Please let us know if you see any transcribing errors and we'll get them corrected immediately. 

Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America's leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers, all available at NAFC.org. 

Welcome back to another episode of Life Without Leaks. I'm your host, Bruce Kassover, and joining us today is Sarah Jenkins, the Executive Director for the National Association for Continence. Welcome, Sarah. 

Sarah Jenkins: Thanks, Bruce. It's so great to be here. 

Bruce Kassover: Yeah, we're looking forward to this one because today our guest is Laura Keyser. She is a Doctor of Physical Therapy and the Director of Clinical Strategy and Global Health at Axena Health. For more than 15 years, she's been a physical therapist and a public health professional with a clinical expertise in women's and pelvic health. So, welcome, Laura. Thank you for joining us today.

Laura Keyser: Thanks. That's great to be here. 

Bruce Kassover: Yeah, we, we understand that you have some very interesting perspectives on women's health, not just here in the United States, but globally. But before we get to that, maybe you just want to share with us a little bit about your journey to today, how you got into physical therapy and your current position.

Laura Keyser: Sure, thanks. So I've had a bit of a varied career, but I would say sort of a common theme, you know, as I describe kind of my history here has been a real focus on rehabilitation – as you said, I'm a physical therapist by training – as well as a focus on capacity building in women's health and maternal and child health.

So, in addition to practicing clinically in the United States, I've spent a great deal of time working in the context of global health, primarily in sub-Saharan Africa. But really in both settings, in the U. S. and abroad, I've been kind of struck by the immense unmet women's health needs, both broadly and, you know, specific to pelvic health.

And so that really led me to pursue my master's in public health about 10 years ago. And that kind of marked a pivot point for me. You know, I'd been seeing patients one-on-one, you know, in the clinic full-time for a long time before that. And I felt like I kept seeing the same stories over and over again.

And I just really had this urge to, to find, you know, more scalable ways to help more women because it felt like the, the waiting list just got longer rather than shorter, you know, as we were building, you know, kind of building capacity, you know, to deliver one-on-one care. So I got my Master's in Public Health and really, you know, began to focus on this kind of scalability, and my interest in digital health was kind of peaked at that time.

And around that time, I was also introduced to the Leva Pelvic Health System, which is the kind-of the main product that Axena Health offers. So it's a kind-of a digital therapeutic device that helps to treat urinary and fecal incontinence in women. 

Bruce Kassover: So that's very cool and really fascinating. So where in sub-Saharan Africa have you been?

Laura Keyser: So I actually lived and worked for two years in the Democratic Republic of Congo, kind of in the eastern part, right on the border of Rwanda. And I was doing, I was actually nested at a local hospital at that time, you know, working for a nonprofit organization that was supporting, really, a variety of rehabilitation programs.

We were kind-of developing a curriculum and obviously delivering care and mentoring local clinicians. And, you know, as I said, kind of, that was the time when I really started thinking, kind of at a systems level of, you know, how do we deliver rehabilitation care? How do we address women's health care?

Not just, you know, at the clinic level, but kind of putting all those pieces together. I've done a lot of work since then in Congo, kind of going, you know, coming and going on shorter trips. But we've expanded some of our work to Rwanda, Nigeria, and Kenya as well. 

Bruce Kassover: And when was this in particular that, that you've been doing this work?

Laura Keyser: I started my work in Congo in 2009, lived there 2009 and ‘10. And it was in 2013 that I developed a really strong relationship with a nonprofit organization that's called Engender Health. And they were doing a lot of programming around that time in fistula care. So obstetric fistula is a really devastating, maybe perhaps the most devastating birth injury that a woman could experience. But really there's been, there's kind-of a hole that develops in the, the wall of the vagina and the bladder or sometimes the rectum, and it leads to continuous incontinence. Obviously, physical therapy won't fix that, it's usually surgery that's needed, but you can imagine the extent of rehabilitation that may be required for women that are experiencing that.

So I was kind-of wrapped into the work that and the projects that were going on with Engender, really, for the last 10 years. I still have a great relationship with them. 

Bruce Kassover: That must have been particularly satisfying, I can imagine. 

Laura Keyser: Absolutely. Definitely challenging, but very satisfying and really exciting to see an organization prioritize rehabilitation.

You know, we often, especially in these types of settings, of course, you know, like there's life-or-death issues that need to be addressed, but it's, you know, as mortality has declined, we see this increase in morbidities and things that, you know, conditions like incontinence that could be amenable to rehab. So it was really, it's just been wonderful to see you know, a non-profit organization emphasize that as well.

Bruce Kassover: Now forgive me for possibly demonstrating my geopolitical ignorance, but if I'm not mistaken, so you were there well after the end of the Rwandan genocide, but it's my understanding that that there's still a very significant issue regarding refugees and camps, and I'm wondering if it was that something that first of all, am I correct, and was that something that you were encountering as well? 

Laura Keyser: Yeah, great. Thank you for that question. So you're right. I was there certainly in years after the Rwandan genocide. But there is and really has been an ongoing active kind of conflict or political unrest in, in kind-of, the Eastern region of Democratic Republic of Congo, right on that border of Rwanda.

So there certainly were a lot of displaced people. We saw this rise in the condition fistula that I mentioned, also sadly a rise in sexual violence and conditions like that because of all of that unrest going on for so long. You know, you can imagine there's a real breakdown of the health care system.

And so, you know, both your basic, you know, health needs are not being met as well as, you know, everything that's going on because of the conflict. 

There's so many needs to, to be met there. But yeah, it was, it was really one of the most incredible experiences of my life to be, you know, living there and, and really was kind of the impetus for kind of how my whole career has unfolded since then having this real global perspective on, on health care.

Bruce Kassover: That's, you know, it's both fascinating and encouraging and motivating, so I, you know, love hearing that, and people who are willing to, you know, really, you know, sacrifice all of the things that we sometimes take for granted here to, you know, go out and do good for people, so I really, you know, appreciate and love hearing that. 

But our audience does tend to be an American one. So I did want to come a little bit back around to talking about the United States and your experience in how you see urinary incontinence affecting women here locally. So can you tell us what you see from the way women encounter, face and try to deal with their incontinence issues?

Laura Keyser: Great question. I think there's a lot of variation. I think while pelvic floor disorders and urinary incontinence has you know, been in the media a lot more in the last, say, 5 to 10 years, and I think more women are talking about it, I still think there's a real, I don't know if ‘stigma’ is the right word, but certainly there's stigma, but, but still a real normalization of incontinence as something that just happens to women, especially if they've had a baby, and that's really been persistent, even in spite of these media, you know, news media articles that are coming out to highlight pelvic floor issues among women.

So I think because of that, women are still really not seeking treatment in, you know, in droves. And when you look at sort of the prevalence of women living with incontinence and compare that to, you know, who's getting treatment, there's a massive, massive discrepancy there. 

Bruce Kassover: Yeah, you know, and stigma is certainly the word that we use, because it's true, and you're right, you do, you see plenty of commercials and you see plenty of products that have helped people feel a little more comfortable talking about it, but I'm sure that in your experience, if it's like the experience that a lot of the professionals we speak with, is that still people don't want to talk. 

Laura Keyser: That's exactly it. 

Bruce Kassover: Yeah, and I'm wondering, as a physical therapist, are most of the patients you see people who come in there specifically because they're having incontinence issues? Is it because they sort-of think that they know something is wrong? How do people get to you in the first place? 

Laura Keyser: That's a great question. So I would say there are some women, certainly, there's always a, you know, a small number of women that are really empowered. They go online, they figure out, you know, physical therapy is a great option. “I have incontinence. I'm going to be proactive.” But I would say that's pretty rare. 

And really what I saw, particularly when I was you know, I was in clinical practice at Hopkins for a number of years, and it took women years to get to me. They may have gone through a number of providers. They may have tried a treatment that didn't work, but then they never followed up to find a treatment that does work.

And often by that time, women have other issues too. So maybe it started with urinary incontinence, but you know, kind of, as with any sort of injury, right. or kind of insult right to our bodies, if we don't address it right away, other things can happen. And so you can develop maybe fecal incontinence, maybe pelvic pain, maybe some sexual dysfunction issues.

And so often I would see women that took so long to get to me that we had a long list of things that we needed to address. And I don't want to say not ‘just incontinence’ because I don't want to minimize the experience of incontinence, but sort of my point being that we could have addressed some of the issues much sooner and prevented a whole host of other problems from developing if women just got to treatment sooner.

Bruce Kassover: That sounds so incredibly familiar. Sarah, refresh my memory: How long do we say that from our surveys we found it usually takes women to go out and actively seek help? 

Sarah Jenkins: Yeah, our surveys and in just general research, we've seen about six and a half years, which is just heartbreaking that women are living with this condition for so long when there are so many treatments that could help them and make a real difference.

Bruce Kassover: So, you're talking about women who, when they come to you, often have additional issues that are either, that either stem from or somehow related to the, the initial incontinence issues that they were having, or that just sort of also happened to be developing as time goes by. So when you see these women, how did you sort of, how does the evaluative process go to sort of help identify all the different things that may be going on and developing a plan to address them?

Laura Keyser: So I think a lot of we were, where we would begin with physical therapy is you know, listening, listening to really what brought that patient to, you know, into sitting right in front of me. Often because it's been a long journey, maybe six or more years, there's a story, right? There's a story there that helps us kind of, you know, trace what's been going on, what's been tried.

And even starting to get back to you know, maybe how did this problem start? You know, was it an injury at childbirth or was it something that happened a long time ago that's really just been progressing over time, or is it a new onset of something? So we'll often do a really, really in depth history taking and a lot of education up front.

Many women don't know what pelvic floor physical therapy is. And so it's, you know, my job to help them understand, you know, really the breadth and scope of my practice and, and help them understand what we can do as an evaluation. You know, we are, you know, physical therapists sort of all have similar training, you know, before we might specialize.

So we're gonna look at the whole body. You know, we may look at you know, the low back and the hips and things like that. And then we often will do an internal exam of the pelvic floor muscles if the patient is amenable to that. And then from there, we just kind of put all the puzzle pieces together and then devise a treatment plan really based on what's bothering the patient the most in terms of her symptoms.

Bruce Kassover: So, if I am one of those people, or if we have one of those people who really isn't sure of what a pelvic floor physical therapist does, after you've had that initial evaluation, what does a pelvic floor physical therapist do? 

Laura Keyser: So so we can do a variety of things. You know, we have a, you know, most PTs, I think, have a wide toolbox of, you know, things to try with patients.

So for urinary incontinence you know, really, the kind of gold standard treatment for that would involve pelvic floor muscle exercises. So, kind-of a training program to strengthen those muscles, develop coordination, maybe develop even the ability to relax those muscles, right? So a muscle has a variety of functions, not just kind of bulking and getting stronger.

And so we'll often put together a program to help those to help women train those muscles as well as deliver kind of a variety of sort of lifestyle interventions or behavioral interventions, if you will. Things like talking about fluid intake, the types of fluids that are consumed and the volume of fluids that are consumed.

We might look at diet if dietary triggers seem to be linked to, you know, maybe urinary urgency, for example. We might talk about weight management or smoking cessation and kind of, you know, general things that may also be helpful for their incontinence. 

Bruce Kassover: See, that's very cool because I would imagine if you were to ask most people, they would think that a physical therapist deals with physical stuff, you know, your muscles, your tissue, and that's really it. But, so, your scope goes well beyond that. 

Laura Keyser: Absolutely. I think, especially in this space and pelvic health where there's such, you know, even among the smartest of us, you know, we don't know a lot about the pelvic floor. It's not something we're learning. It's not something that's really, you know, we're exposed to. So, I think the education piece is so crucial. 

Bruce Kassover: Now, speaking of education, I would imagine that you spend a lot of time talking about pelvic floor muscle exercises, Kegel exercises, and things of that nature. And I also believe that it's one of those things that most people who are listening to this today will have heard of, but a good number of them are afraid of because it seems like some weird mystery and they may have heard that they're hard to do. They're impossible to do. You can't do them right. It's a pain. Maybe you could tell those, tell our listeners who might be holding those feelings the truth about Kegels. 

Laura Keyser: I would love to. Thank you for that question. So I think you're absolutely right. A lot of women will either say, you know, they don't know what they are, they don't know how to do them, or they tried them and they didn't work.

I've heard all of those many, many times. So really the, you know, the gold standard for, you know, for incontinence treatment would be supervised pelvic floor muscle exercise. So getting to a PT or using a device or, you know, some kind of home device like you know, the company I work for, we have a device that allows women to do this at home. There's other products out there as well. But something that really helps a woman know that she's doing those exercises correctly is important. So it can be your, your PT or as I said, you know, maybe your physician, she may be able to help you, you know, instruct you in that, in that exercise program.

But it's, they are really hard to do on your own. So don't be afraid to ask for help from your doctor, your physical therapist, things like that. That said, with the right instruction and supervision, there's great, great data to show that about 60 to 70 percent of women with incontinence, or I should say people with incontinence, will have symptom improvement if they do those pelvic floor muscle exercises, those Kegel exercises correctly and with enough kind of dosage, right?

So, it takes about 8 to 12 weeks to, you know, to kind of develop coordination, really, of any muscle and develop strength of that muscle. That's why if anyone's been to physical therapy for another issue – a knee issue or a back issue – you're often in PT for about 8 to 12 weeks. And there's kind of a physiologic basis for that because that's about how long it takes our mind and our muscles to kind-of learn that coordination and to get stronger.

Bruce Kassover: I think that makes perfect sense because, you know, we were talking about building muscle. And the same way that people who go to the gym build those muscles you can see, this is just a group of muscles that are a lot harder to see. It makes perfect sense that you would have to dedicate some time to get it right.

Now, before I go on, because I did want to start to ask you about Leva and, you know, some device assistance, but Sarah, I wanted to ask you if you had some additional questions that we should be asking regarding, you know, physical therapy and things of that nature. 

Sarah Jenkins: Yeah, you know, the only other thing I wanted to see if you could touch on is some of the other things besides just incontinence that patients with a pelvic floor disorder might be experiencing.

You know, I think people think incontinence is the main one and it certainly is a big one, but, like, I know back pain and constipation and all these other things can be affected by your pelvic floor, which is why it's so important to take care of it. So could you speak a little bit to that and what, you know, if women are noticing some of these things, it might be a good idea to get them checked out.

Laura Keyser: That's a great question, Sarah. Yeah, absolutely. And I guess I'll backtrack just a bit to, as I was talking about kind-of our physical therapy evaluation and, you know, when I educate patients, I'll often have, you know, a pelvic model with me and I'll often say, “You know, I know you're here for, you know, bladder leakage issues, but I'm going to ask you about bowel issues and I'm going to ask you a little bit about sexual health issues as well, because all of those organs sit very closely together, the pelvic floor muscles are, you know, closely related to their function. And so it's important to kind of understand what's going on, you know, throughout the pelvic floor.” 

So we talked a lot about, you know, bladder issues that could be there. Certainly bowel issues, fecal incontinence or bowel leakage is associated with also having bladder leakage. So those two things can go hand-in-hand. And on the flip side, we also see constipation as well. So that's something that many physical therapists can work to treat. And then you know, pelvic pain issues is really a broad category of symptoms that could be related to things like endometriosis maybe, you know, post-cancer treatments, things like that.

So there's you know, a whole range of treatment options for women that are dealing with pain issues. One other thing I'll add is you know, PTs can be really useful during the pregnancy and postpartum kind-of phase both to help with, you know, pelvic floor health, but general musculoskeletal health and ensuring, you know, women stay active and you know, reducing back pain and hip pain and things like that.

Sarah Jenkins: Yeah, that's great. Thank you. I know so many other countries make that such a priority after childbirth, but U. S. does not. Thank you so much. 

Laura Keyser: Absolutely, I know. Hopefully, we'll change that one day. I hope so. 

Bruce Kassover: Well, you did mention a little bit earlier about devices that could also assist you in strengthening your pelvic floor muscles.

And you have a personal, you know, particular involvement with the Leva system. So I'm wondering if you could tell us a little bit about how they might be helpful as well. 

Laura Keyser: Yes, absolutely. And obviously, I will own my bias since I do, you know, work for the company and was very close to building this product, Leva.

And essentially, I came to doing this because, you know, as I mentioned earlier, I had a long wait list of, you know, trying to deliver one on one care. And I also knew that a lot of women with incontinence just weren't getting care at all. You know, we all mentioned earlier, it takes six or more years to get to treatment.

And some women just never get there, or there's places where there are no physical therapists that could provide treatment. So all that said, I was very interested in leveraging smartphone apps and digital health. And then I was introduced to Leva, which it leverages both smartphone, you know, app kind of education and things like that, also pairs with a device that uses motion. So it essentially detects the movement of the pelvic floor, and it can give real time feedback about what the pelvic floor is doing when someone's doing their exercises. This was very intriguing to me as a physical therapist. I had been familiar with other types of biofeedback that are out there.

There's some kind of pressure, and then there's electrical activity, what's called EMG, and those were kind of the two types of devices that had really been around for decades. And I would use them sometimes, not all the time, in my clinical practice. This motion based mechanism was really interesting to me because I'd never seen anything like it.

And of course, as a PT, I'm a mover and I'm interested in how things are moving. And so that piece of the technology was very compelling to me, enough to bring me, you know, from the clinic to really work on, on developing this product. 

Another interesting feature of this is that the device is used in standing. The many women or, you know, men who are used to using pelvic floor kind-of trainers and devices probably are used to using them lying down. And so I thought this was so interesting to get someone standing up and practicing exercises and in the position that they're most likely leaking, right?

So it's a real functional approach to rehabilitating those muscles. Since the product's been developed, we've actually done quite a bit of research to really show that the product is effective and we get great feedback from our patients, both on the, kind of, the device component as well as the, the app component really helps to deliver all that education that I was describing earlier.

There's a lot of tips and tricks what we call pelvic health fun facts and just information for women to you know, to use to dimprove their pelvic floor health. 

Bruce Kassover: Now, is this the sort of thing that a woman might just, you know, who's maybe listening to the podcast now decide, “Hey, I'm gonna get this,” and just, you know, you go online, you go to the website and you get. Do you need a prescription? Should you do it under the guidance of a physical therapist or a physician? What would you recommend? 

Laura Keyser: Great question. So it is a prescriptive device. So you would need to go to your doctor or nurse practitioner or whomever to, you know, to get a prescription.

We do have a website, which I can, you know, of course leave with you that would link to a prescription form. You know, if your doctor is not familiar with Leva, we can certainly send information to them. And there's also an avenue to do a telehealth visit if you're interested in getting Leva.

We are very eager to push for insurance coverage. We have some coverage now and are expanding. So you know, the long-term goal is really to have this covered by all the, you know, all the major health plans. We're not quite there yet, but we're getting there. 

Bruce Kassover: That does take time. It does. It can be challenging.

Laura Keyser: Absolutely. 

Bruce Kassover: So tell me, do the folks at Axena have any clinical data on efficacy? How, you know, how well the Leva system works and perhaps what, you know, patients might expect to see from a results perspective? 

Laura Keyser: Yes, we actually I think that's one thing that really sets our company apart is that we're really committed to data collection and to publishing on our results.

So we have a number of publications at this point. We conducted a large randomized controlled trial where we compared Leva users to women who are doing sort-of Kegel exercises on their own at home, which is a kind of what we would consider maybe standard care at this point. 

So we compared those two groups. We had about 300 women, so approximately 150 in each group, and we were able to show that both groups did improve because we know that Kegel exercises do work, but the group that used Leva, you know, improved significantly greater, and their results lasted at two years. 

So they were instructed to use Leva for eight weeks. They had the option to continue to use it, but you know, we're able to look at the, the user data over time. Very few women actually did use it after that initial eight-week treatment, and results were still durable at two years, meaning they did not need to go back and use Leva to continue to have those improvements in their symptoms.

We saw early results. So women in that trial saw results as early as four weeks. They saw about an 80 percent reduction in leakage episodes. So that was great. And then we used we use a lot, some validated surveys that are very common in pelvic floor research. And so we used those to also track outcomes over time and we were able to show significant improvements there.

Similarly, we use that those surveys in in our app. So, all of our real-world users are filling out those same surveys that the women in our clinical trial also completed, and we just published a paper on almost 1,000 Leva users showing that about 74 percent experience some kind of significant improvement in their symptoms.

So we looked at a couple of different surveys and in that study. So we're really seeing fantastic results. 

Bruce Kassover: That's got to be incredibly encouraging. I mean, you're talking about eight weeks and you get two years worth of relief for those people for whom it works, and relief is up to an 80 percent reduction in symptoms I mean that sounds like it's life changing.

Laura Keyser: Absolutely. I think it is. And yeah, I think, and I think many women are surprised at how, you know once you kind of get over the hump and you engage and are committed to this treatment it really is an, it's an easy to use, you know, at home device that that you can, you know, it, it really optimizes your ability to execute on these exercises.

You know, it's hard to do your exercises at home and sometimes you go to PT and they give you this long paper, but we've really, really tried to kind of streamline things with the device and the app so it's really, really usable and accessible for women. 

Bruce Kassover: If I'm intrigued now, and I want to learn a little bit more, where do I find you online?

Laura Keyser: Sure. So, we have you can go to our website. It's LevaTherapy.com. That's probably the easiest place to go to find information. There's information there for patients. If there's any clinicians that are listening, there's also kind of a whole section there for clinicians who are treating patients with incontinence.

Bruce Kassover: And that's LevaTherapy.com, correct? 

Laura Keyser: That's correct.

Bruce Kassover: Outstanding. So, Laura, as you know, this is Life Without Leaks, and one of the things we always like to ask our guests before we leave is if they have one little bit of advice, a hint, a tip to help our listeners live a life without leaks. So with that being said, would you share yours?

Laura Keyser: I guess, you know, I just would leave with this point that, you know, just because incontinence is common, you know, there's, we know that, you know, over 60 percent of women in the US alone experience bladder leakage. It's not normal. And I think the more we can do to help women understand it's not normal just because it is common, and for them to understand that there are treatment options available.

Don't wait to seek treatment. Relief is possible. And you know, it can sometimes be important to advocate for yourself and to be persistent. There really are a variety of treatment options, not just even the ones we discussed today, but other treatments as well, if those don't work for you. 

Bruce Kassover: Excellent. Those are great words to close out on. So thank you again. I really appreciate it.

Life Without Leaks has been brought to you by the National Association for Continence. This podcast was supported by our sponsor partner Medtronic. Makers of the InterStim Systems for Bladder and Bowel Control. To learn more about the InterStim Systems, visit controlleaks. com. 

Our music is Rainbows by Kevin MacLeod and can be found online at incompetech.com.