Toileting skills are essential for maintaining independence and overall quality of life, and occupational therapists play a crucial role in helping individuals develop and improve these skills. Toileting includes 3 main components: transfer, clothing management, and personal hygiene.
- Transfers: Transfers refer to the physical movements involved in moving to and from the toilet or commode. This includes standing up from a seated position, transferring onto the toilet, and returning to a seated or standing position.
- Clothing mgmt: Clothing management involves the ability to manipulate clothing for ease of toileting. This includes tasks like lowering pants or underwear, fastening and unfastening clothing, and ensuring that garments do not impede the toileting process.
- Personal hygiene: Personal hygiene during toileting encompasses tasks such as wiping, cleansing, and maintaining cleanliness after voiding or bowel movements. This component is crucial for infection prevention and overall well-being.
Activity Analysis and Interventions
In this article the key skills required for toileting from an occupational therapy perspective are broken down into two categories, physical and process skills followed by intervention ideas to target a specific skill component.
Physical Skills:
Mobility/Transfers
Teach the patient the appropriate transfer technique for their situation. Common toilet transfers include stand- step transfers, squat- pivot transfers, and slide board transfers. Another important component of toilet transfers is transitioning from sit to stand/ stand to sit.
| Sit to Stand Blocked Practice | Blocked practice (completing multiple repetitions in a row) with emphasis on hand placement (pushing up from armrests, reaching back before sitting down), standing from various height surfaces, controlling descent when sitting. It is important to practice sit-to-stands from the height of the patient’s toilet in their discharge environment. |
| Transfer Technique/ Sequencing | Teach the individual the correct sequence of steps involved in safe toilet transfers. Emphasize key points like positioning of assistive devices, reaching back to grasp the armrests or handles and locking brakes on a wheelchair prior to initiating transfer. Go over proper body mechanics to increase safety and efficiency of transfer. It may be necessary to practice these transfers on other surfaces (i.e. high/ low mat table in therapy gym) where you have more space prior to trying in a bathroom environment. |
| Durable Medical Equipment (DME) | If necessary, introduce and train the individual on the appropriate use of assistive devices such as transfer benches, grab bars, or raised toilet seats to facilitate safer and easier transfers. Take adequate time during your session to ensure that these devices are properly positioned and secure in the bathroom. |
| Strengthening Exercises | Develop a tailored exercise program to strengthen the muscles involved in transfers, particularly the quadriceps, glutes, and core muscles. Include both seated and standing leg exercises to enhance leg strength and stability. For individuals completing slide board transfers or seated hygiene tasks incorporate upper body exercises targeting shoulders and triceps such as wheelchair pushups. |
Functional Mobility
Navigating obstacles and entering/exiting the bathroom, and negotiating assistive devices or mobility equipment are important aspects of ensuring individuals can safely and independently perform toileting tasks.
| Navigating Obstacles | Provide education regarding removing clutter and tripping hazards within the patient’s bathroom environment at discharge. Practice removing or rearranging obstacles to create a clear and safe path to the toilet. Set up an obstacle course in the therapy gym where patients must negotiate mobility devices around cones or make turns in confined spaces. |
| Entering/ Exiting the Bathroom | Practice ambulating the distance the patient will need to cover from their bed, favorite chair or from another room in the house to their bathroom at home. Gradually increase the distance they ambulate prior to entering the bathroom to simulate their discharge environment. Practice opening/ closing doors and locking/ unlocking. |
Activity Tolerance
Sitting Tolerance: Individuals need to maintain a seated position on the toilet or commode to perform toileting tasks effectively. A limited sitting tolerance can lead to discomfort, difficulties with hygiene, and increased reliance on assistance. A higher level of sitting tolerance results in more comfortable and efficient toileting experiences, reducing the risk of hurried or incomplete hygiene tasks.
Standing Tolerance: Important for tasks such as transferring to and from the toilet, managing clothing, and maintaining balance during standing hygiene tasks. Patients who void sitting down will still typically need to be able to maintain a standing position for 45 sec- 1 minute to complete clothing management and standing personal hygiene. Individuals who urinate standing up may need to practice standing for longer durations.
| Gradual Progression | Occupational therapists work with individuals to gradually increase their sitting and standing tolerance over time, ensuring that they build endurance safely and effectively. Having patients scoot forward in their chair away from the backrest, sit unsupported on the edge of their bed or on a therapy mat, while engaged in a functional task is a good way to work on unsupported sitting balance for toileting. |
| Strength and Endurance Exercises | Provide progressive exercise programs designed to improve the strength and endurance of relevant muscle groups, such as the quadriceps, hamstrings, and core muscles. To work on strength, increase weight/ intensity and decrease repetitions. To work on endurance, decrease weight/ intensity and increase repetitions. |
| Environmental Modifications | Suggest modifications to the bathroom environment, such as the installation of grab bars or raised toilet seats, to enhance safety and comfort during toileting. For individuals with poor sitting tolerance due to low back pain use of a pillow or wedge behind the person may increase their ability to stay in a comfortable upright position while seated on a toilet or commode. If patient’s have pain when sitting on a hard surface therapists may recommend trial of a padded seat cover. |
Sitting Balance
Static Sitting Balance: Refers to the ability to maintain a stable and upright seated position without falling or losing equilibrium. It is crucial during tasks like sitting on the toilet, as individuals need to remain stable and secure while voiding.
| Core Strengthening | Strengthening the core muscles, including the abdominal and lower back muscles, can enhance overall stability while sitting. Exercises good for targeting these muscle ground include seated marching, seated leg lifts, weighted russian twists and lateral bends, and supported sit ups. |
| Seated Balance Training | Engage in specific seated balance training exercises, such as sitting on an unstable surface like a therapy ball or cushion. This challenges the individual to maintain balance while seated, start by practicing with back and/ or upper extremity support and gradually decrease the amount of support provided while the patient engages in a functional task. |
Dynamic Sitting Balance: Refers to the ability to maintain balance and equilibrium while engaged in tasks that require weight shifting outside their base of support. This is crucial for tasks like reaching for toilet paper, performing hygiene tasks, or transferring on and off the toilet.
| Weight Shifting Exercises | Practice weight-shifting exercises while seated to improve dynamic balance control. For example, individuals can shift their weight from side to side or forward and backward while reaching for cones. Increase challenge by weight shifting while seated on unstable or compliant surfaces. |
| Sitting Balance on Unstable Surfaces | Engage in specific seated balance training exercises, such as sitting on an unstable surface like a therapy ball or cushion. This challenges the individual to maintain balance while seated, start by practicing with back and/ or upper extremity support and gradually decrease the amount of support provided while the patient engages in a functional task. |
| Fine Motor and Reach Training | Combine balance training with fine motor coordination exercises. For example, practice reaching for objects of different sizes and shapes while seated to improve dynamic balance and precision. Have patient practice reaching in various directions including down towards ground and posteriorly (emphasizing trunk rotation) to simulate toileting tasks. |
Standing Balance
Static Standing Balance: Essential for tasks such as standing up from a seated position, standing still while toileting, and maintaining stability when dressing or undressing.
| Strength Training | Implement lower extremity strength exercises to improve muscle strength in the legs, particularly the quadriceps, hamstrings, and calf muscles. This can provide greater stability during standing tasks. |
| Use of Assistive Devices | Recommend the appropriate use of assistive devices like canes or walkers, if necessary, to provide additional support and stability during standing and transfers. |
| Balance Exercises | Practice maintaining standing position with unilateral upper extremity support or without upper extremity support as the patient progresses. For more advanced patients, practice maintaining tandem stance (one foot in front of the other), semi-tandem stance (one foot slightly in front of the other), or static standing on a compliant surface to enhance static standing stability. These positions can also be practiced with or without upper extremity support. |
Dynamic Standing Balance: Involves the ability to maintain balance and stability while making controlled movements and weight shifts while standing. It is crucial for tasks such as reaching for toilet paper, performing hygiene tasks, and transferring on and off the toilet.
| Weight Shifting Exercises | Practice weight-shifting exercises while standing to improve dynamic balance control. This can include shifting weight from side to side, front to back, and diagonal movements. |
| Multi-Directional Reaching | Practice reaching for objects in various directions, with unilateral support or standing unsupported, while maintaining a stable standing position. This exercise improves the ability to shift weight and maintain balance while reaching. |
| Dynamic Balance Games | Incorporate interactive and engaging games or activities that challenge dynamic balance. Games like “Simon says” with balance-related instructions can make therapy sessions more enjoyable while improving balance control. |
Fine Motor Coordination
Fine motor coordination is essential for tasks like buttoning, zipping, wiping, and manipulating small objects, which are all integral to toileting. Individuals with coordination challenges may struggle with these tasks.
| Fine Motor Exercises | Engage in fine motor exercises that target dexterity and coordination. Examples include picking up small objects, stacking coins, folding paper, or threading beads onto a string. |
| Task-Specific Training | Provide training and practice in toileting-specific tasks that require fine motor coordination, such as using a zipper or fastening buttons. |
Grip strength
Grip strength is essential for tasks such as holding toilet paper, manipulating clothing, or securely grasping handrails and supports during transfers. Without adequate grip strength, individuals may struggle to maintain control and stability during toileting activities.
| Resistance Training | Implement resistance exercises using hand grippers, flex bars, therapy putty, or resistance bands to strengthen the muscles responsible for grip. |
| Functional Activities | Incorporate functional activities that require gripping, such as squeezing a sponge or stress ball while practicing toileting-related tasks. |
Upper Extremity Range of Motion
Adequate range of motion in the upper extremities is necessary for reaching, dressing, and performing hygiene tasks during toileting. Limited range of motion can hinder an individual’s ability to perform these activities independently.
| Stretching Exercises | Develop a stretching routine to target specific upper extremity muscles, particularly those used for posterior reaching and such as shoulder internal rotation. |
| Joint Mobilization | Use joint mobilization techniques to address any restrictions or stiffness in the upper extremity joints. |
| Functional Activities | Practice toileting-related movements, such as reaching for toilet paper or fastening clothing, to improve range of motion in a functional context. |
Process Skills:
Safety Awareness
Safety awareness involves recognizing potential hazards and taking precautions to prevent accidents, especially in the bathroom where slips, falls, and other mishaps can occur.
| Environmental Assessment | Occupational therapists can assess the bathroom environment for potential safety hazards and suggest modifications, such as installing, removing tripping hazards, checking for adequate lighting, and installing grab bars, non-slip mats, or raised toilet seats. |
| Visual Cues | Use visual cues or signage in the bathroom to remind individuals to check for potential hazards, like wet surfaces, before proceeding with toileting tasks. |
| Photo Cards | Provide patients with photos of bathrooms with safety hazards, have the patient identify the hazard and provide ideas for how to correct it. |
Recall/ Memory
Some individuals may need to be taught new transfer techniques, safety techniques, how to manage adaptive equipment, safe wiping/ hygiene strategies, etc. The ability to recall this information without assistance is important to facilitate independence with toileting tasks.
| Visual Schedules | Create visual schedules or checklists that outline the step-by-step process of toileting. These can serve as memory aids, especially for individuals with cognitive impairments. |
| Verbal Prompts | Use verbal cues and prompts to guide individuals through the toileting process, reminding them of each step as needed. Prompts may be provided for patients that have difficulty transitioning from one step to the next. |
| Routine Building | Establish a consistent toileting routine to reinforce memory. Consistency can help individuals remember and follow the necessary steps more easily. |
Sequencing
Sequencing involves organizing and following a logical order of steps when performing toileting tasks, such as pulling down pants before sitting on the toilet or wiping before standing. Individuals with cognitive impairment or executive functioning deficits may have difficulty sequencing even familiar tasks or progressing from one step to the next.
| Task Analysis | Break down the toileting process into its individual steps and teach each step separately. Gradually combine these steps as the individual becomes more proficient. |
| Visual Supports | Step-by-step picture cards or written instructions can help individuals remember the correct sequence of tasks. |
Sensory Awareness
Sensory awareness involves recognizing sensory cues related to toileting needs, such as recognizing the urge to void and being able to identify when the body has been properly cleaned during hygiene tasks.
| Sensory Integration Activities | Implement sensory integration activities to enhance sensory awareness. These may include activities that involve touch, movement, or proprioception to help individuals recognize and respond to sensory cues. |
| Toileting Schedule | For individuals who are incontinent or unable to recognize the urge to void, setting up a toileting schedule can ensure a patient is making frequent trips to the bathroom, minimizing risk of developing infection for soiled incontinence- wear (i.e. adult diapers). |
Other considerations:
Continence/ Bowel and Bladder Control
Maintaining continence and having control over bowel and bladder functions are fundamental for toileting independence. Individuals need to be able to recognize the urge to void or defecate, control the release of urine and feces, and access the toilet or commode in a timely manner. Occupational therapists provide bladder and bowel training programs to help individuals regain or enhance control over these functions. This may include scheduled toileting, biofeedback, or pelvic floor exercises.
For individuals who are incontinent, training in management of incontinence products such as adult diapers, pads, and pull-ups is important to promote independence with toileting.
Adaptive Equipment/ DME
Occupational therapists assess an individual’s specific needs and recommend appropriate adaptive equipment or DME, such as raised toilet seats, commode chairs, grab bars, or bidet attachments. Additional adaptive equipment that can be implemented during toileting include reachers, toilet wands/ wipe aids, peri bottles, and dressing sticks are other common devices introduced by occupational therapists to increase a patient’s independence with toileting.
Management of Catheter or Colostomy
Individuals with catheters or colostomies may require specialized care to manage these devices during toileting, ensuring hygiene and preventing complications.Occupational therapists educate individuals and caregivers on the correct procedures for catheter or colostomy management during toileting, address skin care and prevention of skin issues that may arise due to catheter or colostomy use and assist individuals in making necessary adaptations to clothing or hygiene routines to accommodate catheter or colostomy management.
Caregiver Training:
Caregivers play a significant role in supporting individuals with toileting needs, especially those with disabilities or limitations. Proper training ensures that caregivers can assist effectively while maintaining the individual’s dignity and privacy. Occupational therapists offer caregiver training programs that cover various aspects of toileting assistance, including safe transfers, adaptive equipment use, catheter/colostomy care, and maintaining hygiene.
Summary
Occupational therapists play a vital role in addressing toileting challenges by focusing on enhancing an individual’s independence, safety, and overall well-being. They assess an individual’s physical and cognitive abilities, as well as any environmental or adaptive equipment needs. Occupational therapists develop personalized strategies and interventions, which may include exercises to improve strength, balance, and mobility, cognitive training for memory and sequencing, recommendations for adaptive equipment like raised toilet seats or grab bars, and caregiver training when necessary. Their goal is to empower individuals to perform toileting tasks with confidence, maintain continence, and maintain their dignity and privacy, all while promoting safety and improving their quality of life.