Further Enhancing Non-Pharmacological Therapy for Incontinence

描述（由申请人提供）：尿急迫性尿失禁（UI）是不自主的尿漏，伴有突然的小便欲望。普遍、病态、昂贵（2000年每年将近200亿美元）的尿失尿症是老年人的主要问题。虽然它通常被归因于膀胱痉挛（也称为逼尿肌过度活动[DO]），但尿失禁的实际原因尚不清楚，治疗仍然不充分，在过去的50年里几乎没有改善。使用生物反馈（BFB）的行为疗法与药物治疗一样成功，而且更安全，但很少使用，因为它需要设备、专业知识和时间，而这些都不是广泛可用的。我们正在进行的研究的目标是确定预测BFB反应的因素，更重要的是，BFB是如何工作的。这样的理解将使医生进一步提高其疗效，简化其交付，并促进其更广泛的应用。然而，这项正在进行的研究表明，最重要的因素不在于下尿路，而在于大脑控制它的方式。虽然对这种大脑控制知之甚少，但我们的初步研究表明，可以确定关键区域，以及这些区域之间的联系，并且这些中心在控制膀胱的老年人和患有尿失禁的老年人中的功能方式存在差异。为了证明这些中心参与其中，这些发现必须在一个单独的、更大的老年人群体中得到证实。此外，如果这些数据是正确的，那么患有UI的人的大脑异常应该随着BFB的临床反应而改善。因此，本提案的具体目标是：(1)在更大的老年妇女群体（60岁以上）中证实这些试点结果，这些老年妇女有或没有尿失禁；(2)确定脑梗死患者的脑异常表现是否因BFB而改善，以及这种改善是否与临床改善相一致。为了实现这些目标，受试者将在8周的BFB课程之前和之后进行研究。评估将包括临床评估，下尿路功能的详细测试，以及使用功能磁共振成像（fMRI）进行非侵入性脑成像。将BFB治疗后的结果与治疗前的结果进行比较，并将临床改善与脑异常变化进行比较。此外，因为这些人中的一些人即使他们的DO持续存在也会成为大陆，他们的大脑变化将与那些DO消失的同龄人进行比较。这项研究的知识可以为老年人尿失禁的原因以及成功治疗的机制提供重要的见解。反过来，这些知识应该有助于设计更简单、更有效的治疗方法，让更多的人受益。学习控制膀胱是儿童发展的一个里程碑，而作为一个成年人，失去控制膀胱可能是一个灾难性的经历，往往会损害独立和积极的生活。这种情况的原因尚不清楚，因此治疗不是很有效，而且针对性很差。由于生物反馈辅助膀胱训练是现有治疗方法中最有前途和最安全的，有关其工作原理的新知识可以使其变得更加有效和更广泛。

DESCRIPTION (provided by applicant): Urinary urge incontinence (UI) is involuntary leakage of urine that is accompanied by a sudden desire to urinate. Prevalent, morbid, and costly (nearly $20 billion annually in 2000), UI is a major problem for older adults. Although it is generally ascribed to bladder spasms (also known as detrusor overactivity [DO]), the actual causes of UI are unknown, and therapy remains inadequate and little improved over the last 50 years. The recommended first-line treatment behavioral therapy using biofeedback (BFB) is as successful as medications and safer, but it is rarely used because it requires equipment, expertise, and time that are not widely available. The goal of our ongoing study is to determine the factors that predict BFB response and, more importantly, how BFB works. Such understanding should allow physicians to further enhance its efficacy, streamline its delivery, and facilitate its more widespread application. However, this ongoing study is suggesting that the most important factors reside not in the lower urinary tract but rather in the way the brain controls it. While little is known about such brain control, our pilot studies suggest that the key areas can be identified, as can the connections between these areas, and that there are differences between the way these centers function in older people who remain in control of their bladder and in those who develop UI. To prove that these centers are the ones involved, the findings must be confirmed in a separate and larger group of older adults. In addition, if these data are correct, then the brain abnormalities in people who suffer from UI should improve in concert with the clinical response to BFB. Thus, the specific aims of this proposal are: (1) to confirm these pilot findings in a larger group of older women (>60 years old) with and without UI; and (2) to determine whether the abnormal brain findings in those with UI improve with BFB and whether such improvement parallels the clinical improvement. To address these aims, subjects will be studied before and after an 8 week course of BFB. The evaluation will include a clinical evaluation, detailed testing of lower urinary tract function, and non-invasive brain imaging using functional magnetic resonance imaging (fMRI). Findings after BFB will be compared with those before therapy and clinical improvement will be compared with change in the brain abnormalities. In addition, because some of these people will become continent even though their DO persists, their brain changes will be compared with those of their peers in whom the DO resolves. Knowledge from this study could shed important insights into the cause of UI in older adults, as well as the mechanisms that underlie its successful treatment. In turn, such knowledge should facilitate design of therapy that is simpler and more effective so that more people can benefit.Project Narrative The learning of bladder control is a milestone in child development, and the loss of bladder control as an adult can be a disastrous experience and one that often can compromise an independent and active life. The causes of this condition are not clear, and thus therapy is not very effective and is poorly targeted. Because biofeedback-assisted bladder training is the most promising and safest of available treatments, new knowledge of how it works could allow it to become even more effective and more widely available.