Long term care facilities affiliated with The Ensign Group are tapping into the power of technology to treat urinary incontinence and seeing results for residents. They are using Percutaneous Tibial Nerve Stimulation (PTNS), a procedure that aims to help patients with overactive bladder, along with symptoms of urinary urgency and/or frequency, improve their quality of life.

How it Works

During the procedure, which is often performed by a physical therapist, physician, or a nurse practitioner, the resident is in a comfortable position with their lower extrem­ity slightly externally rotated to expose the inner side of the ankle. The area is prepped with an alco­hol swab and an acupuncture-like low gauge needle is inserted into the tibial nerve pocket, connected to the NURO™ device by Medtronic. The device is turned on to send electri­cal pulses to the afferent fibers of the tibial nerve.   

The procedure helps restore communication between the bladder and the central nervous system and improve bladder function.

Jon Anderson has been a physical therapist serving affiliates of The Ensign Group for the past 13 years. He currently oversees the organization’s Texas operations for therapy. “We use that nerve because it’s the same nerve root that innervates the bladder,” he says. “So if you downregulate that—that’s what this does—it downregulates the activity of the  nerve down at the ankle, that will send that signal all the way up to the spine and every muscle that that particular nerve innervates; it downregulates the muscle activity.”

The detrusor muscle of the urinary bladder is active and contracted, Anderson explains. “And when it’s contracted, it’s pressing up against the bladder wall, and it’s creating less room for urine capacity. So if it’s relaxed, it allows the bladder wall to have more capacity, and we’re able to fill it up more.”

Steady Adoption

In the urology/urogynecology clinics, the treatment isn’t new. It has been a mode of treatment for well over a decade and is a part of American Urology Association’s Overactive Bladder Treatment guidelines.  Still, Anderson is part of a small niche group that does it. The reason for slow adoption? 

“Before it was something that you would go to your urologist to have done,” he says. “When you think about the number of urologists for patients needing this type of treatment, the available limited physician time, the recurring visits involved, and compounded typical physician wait times, many patients wouldn’t attend enough treatments for the benefits to kick in.”

Knowing the void existed especially in long term care, he along with members of his staff is leading a charge to change that.

As the chair of the practice committee of the Texas Physical Therapy Association, Anderson had helped write a white paper on physical therapists providing dry needling.  The PTNS needles are in the same class as dry needling needles, and physical therapists were already using them for various therapy services such as neuromuscular reeducation, and to decrease pain. 

So Anderson reached out to the Physical Therapy Board to get clarification. The board agreed and cited an attorney general opinion that physical therapists are competent and knowledgeable to perform the procedure.

Ensign Group affiliates soon began offering the procedure in some of its facilities in San Antonio, along with an internal study to see what the improvement in patients’ bladder capacity would be. The patient’s bladder capacity was assessed prior to providing the treatment, and the team assessed other factors like how many changes residents were needing, how often they needed to go up to the restroom, and what their bladder capacity was after 12 weeks of treatment.

“We found that 50 percent of patients had significant improve­ment, meaning that they had at least one less change a day, and they had a significant improvement in their bladder capacity,” says Anderson.
Ensign Group affiliates currently offer the treatment in Texas, Iowa, and Wisconsin and are working on expanding to other states.