I am CAPP- Pelvis certified. This is a way of signifying my dedication to women’s health physical therapy. CAPP-PELVIS certification is awarded through the Women’s Health section of the American Physical Therapy Association(APTA). It is awarded to physical therapists who complete required education, training and testing related to pelvic health dysfunction. One of the requirements is to write a case study and have it approved by American Physical Therapy Association.
Below is my case study – I want to present it in this blog as way for people to learn some of what I do at SBR Therapy and Wellness to treat Women’s Health (and Men’s) Issues. Also, If you are interested in preventing or lessoning some of these risks I can assist with that too. I have treated thousands of patients with pelvic health issues and done thousands of internal and external pelvic floor exams.
Pelvic Health Issues can include, but are not limited to : urinary incontinence, pregnancy and postpartum, bowel dysfunction, pelvic pain conditions, post pelvic, abdominal surgeries; craniosacral alignment issues, pain with intercourse, testicular pain, Male or female pelvic pain, myofascial pain, pelvic/hip/back pain with sport, scars.
Here is my article – let me know if you find it helpful! Let me know if you would like help – you can book online with our app, or call sbrtherapy.com 262- 204 – 8383
How to treat bladder and bowel incontinence with focus on a whole body approach (An evidence-based case report)
Case Study for CAPP-Pelvic Completion
Submitted: November 8, 2015
Date of PF3: November 8 – 11, 2014
Jeanie Crawford DPT, CMTPT
The purpose of this case report is to gain insight on how knowledge from didactic course work and scientific based evidence has been able to effectively treat pelvic floor patients.
This specific case was chosen to show some classical signs and symptoms a physical therapist treating women’s health patients will see while treating someone with bowel and/or bladder incontinence. The whole person approach was used: incorporating the patient’s daily life, her personal goals, and her functional limitations related to her impairments. This case will discuss specifics of how to examine and diagnosis a patient with bladder and bowel dysfunctions. Furthermore, interventions were chosen based on scientific research and their outcomes will be discussed.
Multiple comorbidities have been associated with incontinence. These may include: urinary tract infections, constipation, depression, prolapse, chronic obstructive pulmonary disease, asthma, diabetes, cystic fibrosis, and labor/pregnancy.1,2,3 However special consideration must be given to rule out cauda equine, radiculopathy, and central or peripheral nerve involvement. These often mimic many of the signs and symptoms seen with bowel and bladder incontinence.
Patient was a 36 year-old married female working at a desk job, referred by an urogynecologist for bladder incontinence. Patient’s primary complaint was bladder incontinence; however she also had complaints of bowel incontinence. She reported inability to hold back gas and having small amounts of bowel movement between her buttocks. The patient described her bladder incontinence as both stress and urge incontinence (also known as mixed incontinence). Symptoms of stress incontinence were reported including: leaking with jumping, workout videos and jogging. Furthermore she described her symptoms of urge incontinence in that she was having a strong urge to urinate whether her bladder was full or not. Along with the urge she reported increased urination frequency, going two to three times in one hour to avoid leaking and to stop the annoying urge sensation. The patient reported having some incontinence prior to having her children who are now 4 and 6 years old. She knew where all the restrooms were while in the community.
Both of her children were delivered vaginally. She had an episiotomy with her first child, and a 3rd degree tear with her second child. An episiotomy is a surgical incision at the vaginal opening to aid in the delivery during childbirth or to prevent rupture of tissue at or near the genital hiatus (vaginal opening).4 Unlike episiotomies perineal tears happen naturally in that no incision is made. Tears have been consistently classified within research articles and information sites online. A 2nd degree tear involves tearing of the pelvic floor muscles, while a 3rd degree tear further tears the vaginal opening to the edge of the anus or through. Lastly a 4th degree tear is defined as a tear all the way through the anal sphincter muscle to the anal epithilium.5,6 The anal sphincter muscle is a ring of two muscles at the opening of the anus, these are the internal and external anal sphincters. These sphincters are under voluntary control to open and close the sphincter to allow bowel movement to be stored or passed.7 When this is torn or cut there is a risk for incontinence of gas and/or bowel secondary to damage of this muscle whose job is to hold back gas and bowel until ready to be passed.8
Research has shown that episiotomies that are cut at 60 degrees may prevent against obstetric anal sphincter injuries.9 Studies have also demonstrated that the angle doctors and midwifes are reporting to be cutting at are not the angles they are actually cutting at.10 Therefore it might behoove mothers to discuss episiotomy options with their doctor or midwife prior to delivery to avoid risk of bowel incontinence.
On a severity scale of bladder symptoms from 0 being no problem to 10 being a severe problem the patient rated her bladder problem to be an 8 out of 10. This scale is not a research-documented scale, however it is one question that this writer has found helpful to subjectively monitor patients’ progress. Patient reports that her symptoms were getting worse, in that she found herself consistently needing to use the restroom at work and work events. The volume of leaking with stress incontinence was reported to be drops to squirts of urine with more constant physical activity. Incontinence of bladder while running or attending workout classes was a daily problem. Patient approximated using the restroom 12 times a day (3 before work, 5 times during work, and 4 times after work). According to the bowel and bladder foundation normal urination in a 24-hour period is 6-7 times, and as low as 4 and has high as 10.11 The patient reported using the restroom to urinate 0-1 times at night, which is within normal limits.11 She used 0-1 pads a day and always wore a pantiliner while working out. The patient could delay the urge to urinate for 5 minutes. She denied burning with urination, painful urination, or difficulty starting urination.
There is a risk of bladder incontinence during pregnancy and post pregnancy independent of whether delivering vaginally or cesarean.2,7 Studies have also shown that the risk is equally high among females who have never been pregnant. One study indicates 50% of female collegiate athletes experience bladder incontinence. 12
The patient rated her severity of bowel symptoms a 4 on a 10-point scale (not a research based outcome measurement tool), with the symptoms being unchanged following the delivery of her first child. She was having 1-2 bowel movements a day. When having an urge to evacuate bowel, she was unable to hold the urge at all. Sometimes she would leak on the way to the restroom. When at the store, she would not be able to wait until she got home to use the restroom. Staining of her underwear or bowel movement between her buttocks was reported. Her normal bowel was reported as a Type 4 on the Bristol stool scale, which is considered normal and ideal. This would be smooth, soft and formed; like a sausage or snake. The Bristol Scale goes from a Type 1 to a Type 7. The Bristol scale is a short visual and word description of different types of bowel, ranging from type 1(separate hard lumps) to type 7 (watery no solid pieces).13 Furthermore she had a history of Irritable Bowel Syndrome (IBS), however at evaluation date she was not having any symptoms of IBS. IBS can include cramping pain, bloating, gas, mucus in the stool, and changes in bowel habits. Some people with IBS have constipation while others have diarrhea, or a combination of alternating constipation and diarrhea.14 Fecal incontinence is commonly seen with patient’s diagnosed with IBS.15
The patient’s current dietary habits included drinking 48-64 ounces of water, no caffeine, and 8 ounces of juice. Many liquids other then pure water have been linked to bladder irritants. Included in these are: caffeine, alcohol, carbonated beverages, teas and drinks with aspartame and saccharin.16, 17 The patient was aware of this knowledge from her referring physician and had already chosen to avoid possible bladder irritants.
The patient denied low back pain, dyspareunia (pain with intercourse), or lower abdominal pain. Furthermore she denied any history of sexual abuse or trauma. She reported no abdominal surgeries, no pelvic surgeries, and her menstruation cycle was regular. Lastly, the patient denied any: weakness, numbness, and/or tingling.
The patient’s goals for therapy were 1) to have less frequency of urination, 2) to decrease incontinence of urine, 3) to be able to hold back gas, and 4) to be able to eliminate accidental bowel movement in between her buttocks.
The patient fulfilled criteria for a pelvic exam. Prior to evaluation the patient was educated in normal pelvic floor anatomy and physiology. The patient did not fit into any category that would deem an internal examination cautionary or contraindicated.18 In that the patient had no current infection, was not pregnant nor post partum, had not undergone recent surgery of any kind and specifically not of abdominal or pelvic region. Furthermore she denied sexual abuse or pain with pelvic exams. The patient gave verbal and written consent prior to her pelvic exam.
The patient’s summary score was a 132 (range 0-300) on the Pelvic Floor Distress Syndrome Inventory-20 (PFDI) outcome measure questionnaire. This questionnaire was chosen to assess the affect of her incontinence on her quality of life. It is a 20-item questionnaire that addresses: urinary incontinence, fecal incontinence and pelvic organ prolapse, and constipation. A higher score indicates the pelvic floor disorder has a greater negative impact on the patient’s life.19,20
In standing the clinician observed and palpated multiple abnormalities. The patient was noted to have protracted shoulders and decreased development (atrophied) of her upper thoracic extension musculature at thoracic levels 1 through 4. Atrophy was palpated and observed at her multifidi, middle trapezius and rhomboids at her upper thoracic spine. She had elongated upper trapezius muscles. The pectoralis muscles bilaterally were shortened and with multiple taut bands and latent trigger points. Thoracic levels 1 through 4 were flexed; she extended at thoracic vertebral level 5. Then she went back to being flexed from thoracic levels 6 to 11. There was hypermobility with excessive movement at thoracic spine level 9. When looking and palpating further down the trunk, her external obliques were visibly and palpably tight bilaterally. She had notable atrophy of her bilateral gluteus maximus musculature. Her multifidi were atrophied at lumbar levels 4 through sacral level 1 bilaterally. Her innominate was rotated anteriorly on the right and her posterior superior iliac spine was slightly higher on the left. The alignment of the spine, pelvis and hip is important when looking at a patient with pelvic dysfunctions; misalignment is a potential cause of incontinence and low back pain.21 Arguably when treating incontinence you are not treating the patient any different then one would if they had lumbopelvic instability.22 According to Hides et al. research the multifidi muscle can stop contracting in patients with low back pain and has been shown not to be active even a year later when the pain is gone.23 Clinically this (atrophied multifidi) is a classical symptom seen if one is looking while examining a patient with pelvic floor pain, dysfunction, or incontinence. Dianne Lee speaks of the “circle of integrity”.24 The combination of the transverse abdominus and the multifidi ability to contract provides support by means of the thoracolumbar fascia tensing and thus making a circle around the lumbopelvic region.24 Fascia and muscle surrounding the lower core are of importance for stabilizing and providing “forced closure” by means of fascia and muscle.24
Upon further observation and palpation, trigger points were noted at her quadratus lumborum, rectus abdominus bilaterally (upper bellies greater then lower bellies), and her external and internal obliques bilaterally. A trigger point is a hyperirritable tender spot that is usually found within a taut band of skeletal muscle or fascia.25 An active trigger point causes spontaneous pain that can be local and/or referred pain.25 Latent trigger points are not actively or currently causing pain, however when palpated can cause local or referred pain just as an active trigger point.25 The significance of trigger points, whether active or latent is that they can cause decreased range of motion, functional and biomechanical limitations.26 The rectus abdominus specifically the upper bellies has been linked somatoviscerally to detrusor and urinary sphincter spasms.27 Interrater reliability to identify a trigger point is excellent for those trained in identifying trigger points.28 The clinician examining this patient is a certified manual trigger point therapist.
There were no visible scars on the abdomen. The patient’s inter-recti distance measured with diagnostic ultrasound was 4.5cm at its greatest width at the umbilicus and continued caudally for 2.5 inches toward the pubic bone. The linea alba runs from the xiphoid process to the pubic bone, it separates the left from the right rectus abdominus bellies. While the fetus grows in the mothers uterus, the linea alba can thin and elongate in the horizontal plane.29 The horizontal distance between the rectus abdominus musculature is referred to as the inter-recti distance; the average inter-recti distance is .9cm from half-way between the pubic bone and the umbilicus, 2.7cm just above the umbilicus and 1.0cm half-way between the umbilicus and xyphoid.29 Diagnostically diastasis rectus abdominus is anything outside of these normal means.29 Rath et. al has used 2.7cm and greater as a diagnostic criteria for diastasis rectus abdominus.30 Studies have shown increased risk with pregnancy to develop diastasis rectus abdominus.31 Again this is another site that can cause weakness at the “circle of integrity”.24 The most common site of diastasis rectus abdominus is at the umbilicus, and left untreated has been linked to lumbopelvic pain and both bowel and bladder incontinence.31,32
Clinically this therapist has noted increased pigment changes at the linea alba where the diastasis rectus abdominus is identified, in this patient and many others. Although there is no known research (to this writer) to connect the pigmentation to diastasis rectus abdominus, this writer believes it is from toxins within the stomach being released through the thinning linea abla tissue. The toxins are able to exit there secondary to the thinning of the linea alba. Furthermore, this writer would argue that the inter-recti distance is less important then the thickness and tone of the linea alba at the inter-recti distance in providing lumbopelvic stability. This tension is needed to 1) provide support for the rectus abdominus to develop muscle mass and 2) for direct support from the pubic bone to the xyphoid process to prevent extension of the spine and anterior tilt of the pelvis.
The patient was noted to over-recruit her upper trapezius muscles and scalenes while breathing in sitting, standing and supine. She was an upper intercostal/chest breather. The patient had minimal to no use of her mid costal musculature. The restrictions with costal expansion were anteriorly, posteriorly, and laterally at her mid and lower intercostals. This will restrict normal breathing. The costal expansion was restricted directly by weak internal and external intercostal musculature and indirectly by muscular attachments of her tight rectus abdominus, obliques and quadratus lumborum. Normal breathing would be full expansion of diaphragm with inhalation allowing dropping of pelvic floor, followed by expansion of intercostals 10-12, and finishing with intercostals 1-9. 33
Gillett’s Sacral Fixation Test for hypomobile sacroiliac crest was negative bilaterally.34 Sacroiliac compression and distraction caused her no pain. There were no leg length discrepancies, with both the long sit test and with measurements from her anterior superior iliac spine to her medial malleoli.34 During the bilateral leg raise test the therapist noted hyperextension of her lumbar and thoracic spine. However with the assist of the therapist compressing her pelvis at her iliac crests she was able to hold neutral spine, indicating weak functional use of her transverse abdominus.24
The patient’s hips and core were weak bilaterally. While squatting, patient compensated with increased activation of her upper thoracic and scapulothoracic musculature, along with excessive anterior tilt. When transferring from supine to sit she used her upper extremities on the posterior aspect of her thighs to assist with herself with lifting her trunk. Hip abduction, adduction, and external rotation were 4/5 bilaterally with manual muscle testing. The patient’s transverse abdominus strength was 1/5 with Modified Sahrmann Lower Abdominal Testing.35 This indicated that in hook-lying the patient could lift one foot while holding her lower back in a neutral lumbar position.
Pelvic Floor External and Visual Perineal Assessment:
The patient’s skin was intact and appeared healthy upon visual examination of her mons pubis, labia, vaginal hiatus and rectum. There was no erythema, opens sores, or signs of infection or disease. Her skin between the vaginal hiatus and rectum appeared thinned along her healed episiotomy scar. A small skin tag was noted at the rectum indicating a healed external hemorrhoid. With flat palpation, trigger points were identified at her ischiocavernosus and superficial transverse perineal muscles on the left. When the patient was asked to do a kegel, the skin around her labia and rectum pulled upward and activation of her levator ani was felt just inferior to her superficial transverse perineii in the lithotomy position. During a valsalva response (coughing), a reflexive contraction response was noted at the rectal sphincter and vaginal hiatus.
Vaginal and Anal Internal Assessment:
Upon vaginal examination the strength of her levator ani (coccygeus, iliococcygeus, and puborectalis) was assessed using the “PERFECT SCALE” and the “Modified Oxford grading scale”. PERFECT is an acronym for power, endurance, repetition, fast, and “ECT” for every contraction timed.36 Power and strength and endurance were measured using the oxford grading scale.36 The power of her left and right levator ani was a 3/5, she was tighter on the left versus the right with palpation of her pelvic floor. A grade 3 is considered moderate strength, enough to see a lift at the perineum and a lift felt internally. The endurance of her levator ani was 10 seconds. She was able to repeat 10 second holds with 4 second rests for a total of 4 repetitions. She was noted to fatigue greater then 35% at her 5th repetition of 10 second holds. An elevation of her pelvic floor was noted bilaterally. The number of repetitions of kegels she could do in a 10 second period was 6. During these quick contractions she was instructed to come to a full contraction and a full relaxation for consistency with testing. Her ability to elongate her levator ani was worse on the left; this decreased mobility was noted more posteriorly versus anteriorly. There was tightness felt at her coccygeus and puborectalis muscle on the left greater then her right. Patient’s ability to return from the contracted state of her levator ani to a relaxed state was delayed on the left and the right. Co-contraction of her transverse abdominus and levator ani was present. It is considered normal to have firing of the pelvic floor simultaneously with the transverse abdominus.37 When the patient was instructed to contract her levator ani in isolation, she was unable. She recruited both her internal obliques and adductors bilaterally and quite symmetrically. This is an abnormal finding.37, 38 Trigger points were palpated internally at the obturator internus and the superficial transverse perineal on the left. Puborectalis had multiple trigger points bilaterally. Patient’s sacrotuberous and sacrospinous ligaments were tighter on the left versus the right. The patient denied pain at her urethra, bladder, and bladder neck with palpation.
Prolapse of vaginal anterior wall was noted has a grade 1 cystocele. According to the Gynecological Manual by the American Physical Therapy Association a grade 1 cystocele is a mild bulge in the anterior canal of vagina involving the bladder only. The prolapse was above the hymen.39
Rectally, the patient’s strength was a 2+/5 on the left and the right sphincter muscles. The patient had a palpable gap at 12 o’clock at her sphincter muscles. She was able to hold a weak sphincter contraction for 10 seconds. The sphincter muscles were loose. No significant grip or clamp was felt upon entering or exiting the rectum.
The diagnosis on the order from the referring urogynecologist was bladder incontinence. The physical therapist diagnoses include: bowel incontinence, bladder incontinence (both urge and stress), and diastasis rectus abdominus. As a physical therapist specializing in treating bladder incontinence for the past 5 years, it is common to find multiple musculoskeletal imbalances that contribute to lumbopelvic instability and therefore incontinence of both bladder and bowel.22,24,27,32 Within the three diagnoses, below the writer will try to point out the musculoskeletal imbalances noted in this case study.
The potential differential diagnoses ruled out included: diabetes, urinary tract infections, constipation, depression, chronic obstructive pulmonary disease(COPD), asthma, diabetes, cystic fibrosis, and labor/pregnancy.1,2,3 Upon further questioning and review of the patients chart in epic, urinalysis test for urinary tract infection was negative. The patient did not report current or past history of diabetes. There were no reported or noted breathing difficulties. Furthermore her chart was negative for pulmonary issues. Other differential diagnoses to consider and rule out were cauda equina, radiculopathy, and central or peripheral nerve involvement. The patient had no motor or sensory deficits indicating central or peripheral nerve involvement. In that the patient was cognitively intact, there were no coordination difficulties noted or reported, and she had no gross motor nerve pathway deficits. Furthermore, the patient denied numbness, burning, tingling or sensation changes.
The proposed mechanism of injury for her bowel incontinence would be her 3rd degree tear with vaginal delivery or could have been caused by her episiotomy depending on the episiotomy angle. The palpable gap at 12 o’clock when assessing her sphincter indicates sphincter muscle damage. The gap was felt as a thinning or in other words less bulk of her sphincter muscle. This will limit her sphincter integrity and potentially predispose her for incontinence of bowel and/or gas.4,5,6
The patient’s cause of her diastasis rectus abdominus most likely evolved from bearing two full term children and weakness of her core musculature due to poor mechanics and posture.22
Her type of bladder incontinence is subjectively both urge and stress incontinence; which could also be called mixed incontinence.7 Bladder incontinence was reported as urge prior to having her children and a combination of urge and stress following the childbirth of her two children. The therapist hypothesized the cause of her bladder incontinence to be multifactorial. The potential contributing factors to the patient’s urinary incontinence included: 1) atrophied multifidi in her lumbar spine and atrophied gluteal musculature (gluteus maximus), and her weak and tight hip rotators, 2) tight and overactive pelvic floor and urethra sphincter, 3) abnormal breathing patterns, pelvic obliquities and poor posture.
The multifidi muscles help complete the circle of integrity along with the transverse abdominus for lumbopelvic stability.22, 24 The patient also had atrophied gluteus maximus, which assists in stabilizing the pelvis with weight bearing.40 The lack of this extra support to the spine will place increased stress at lumbar spine thus weakening her lumbopelvic stability further. Furthermore, the external and internal rotators of hip being tight constantly correcting for imbalances could potentially reposition the sacrum and therefore her pelvic floor and indirectly.
The patient had tight, weak, and unbalanced pelvic floor musculature.41
The patient’s dysfunctional pelvic floor muscles could be from overuse, underuse, neurological trauma at the delivery of her children, and/or musculoskeletal imbalances in her core. The pelvic floor acts as a shelf to hold up the bladder, urethra, and bowel. Urethral closure pressure needs to be higher then abdominal pressure in order to maintain continence.7 When the pelvic floor contracts it lifts the urethravesical neck. Furthermore, the levator ani provides a counter pressure against gravity and therefore can change the abdominal pressure. A normal resting tone is ideal when working with the pelvic floor. As an overactive or abnormally tight levator ani can cause fascial and/or visceral pull on the detrusor and the urethra sphincter. Maeve Whelan has compared in lecturing the pelvic floor to an elbow with restricted range of motion, when not complete it is dysfunctional.42 Not only is it dysfunctional at the elbow but also can affect the glenohumeral joint and scapula-thoracic joint. This lack of range of motion and mobility can affect the overall shoulder girdle. Similarly, the pelvic floor muscle tightness can affect the lumbopelvic junction and hip joint.
Notable also was the patient’s overactive external obliques with breathing, with her voluntary “kegel”, and at rest. This abnormal response will then compress the fluid filled abdomen usually caudally following the line of gravity onto the pelvic floor. 43 Furthermore the patient has poor mid intercostal strength adding to poor breathing mechanics and thus increased stress on the pelvic floor.43 Lastly the patient had pelvic obliquities, most likely stemming from muscle imbalances. All of these factors could potentially contribute to urinary incontinence.
Prognosis and Plan of Care:
Prognosis was good overall for control of her bladder continence. Patient was young, motivated to make life style changes, had good communication, was cognitively intact, had health insurance and appeared to have had a healthy living situation (married to a working husband, her kids were healthy, she also worked full time). The plan to treat her bladder incontinence was multifactorial. Patient had to be educated on normal bladder patterns, which would be discussed with patient after she completed the bladder diary. The bladder diary would have to be completed first in order to have her baseline to compare her results against norms for urine frequency and amount. Furthermore, the bladder diary can be used to motivate the patient has progress is seen with less leaks and trips to the restroom as she progresses in therapy. The bladder diary would record seconds of urination, frequency of urination, and any incontinence that occurred and how many pads she went through. The levator ani would have to be released to restore normal range of motion; furthermore her levator ani would have to be strengthened. The plan was to use manual trigger point release and thiele massage for the release, and kegel exercises for strengthening.44 Thiele massage is a technique that involves strumming from origin to insertion perpendicular to pelvic floor muscle fibers, for a period of 5 minutes to the taut bands.44 Manual trigger point release technique is done by identifying the nodule within a taut band by strumming the band perpendicular to the line of the muscles fibers. Once the hard nodule is identified pressure is placed on the nodule (trigger point) and held until the release is felt.25 She would also need to get her transverse abdominus firing to further support the lumbopelvic junction.24,45,46 This would simultaneously address her diastasis rectus abdominus. Both of which will contribute to lumbopelvic stability.21,22,24 In order to activate her transverse abdominus, real time ultrasound imaging would be used in order to 1) provide biofeedback for the patient and therapist as to the best cuing to active the transverse abdominus, 2) further verify that her transverse abdominus was firing versus palpation alone, 3) look at symmetry between left and right, and also 4) assess the ability of her linea alba to tense and not bevel.37 The plan was to progress her transverse abdominus strengthening from lying down to all functional movements (quadruped, kneeling, standing, squats, walking, activities of daily living, workouts). The positions would be progressed based on the patients ability to tense the linea abla and avoid beveling at the diastasis, along with tenseness felt at her transverse abdominus.37,45.46 Another objective was to activate her multifidi to further complete the “circle of integrity”.21,22,24 This would be done by dry needling and electrical stimulation. Dry needling is used to restore range of motion and dysfunctional motor units. Dry needling is the use of a needles to release trigger points.25 The width of the needle used would be .3mm (three times the width of a muscle fiber) and 50mm long.25 Intramuscular electrical stimulation was used to further initiate activation of her multifidi muscle, restore normal range of motion of the multifidi, and strengthening her multifidi of her deep spine.47 The ITO ES-130, 3 channel Electro Stimulation Unit would be used. The parameters would be set at 4hz for 10 minutes directly, with the 3 channels connected to the needles at the lumbar multifidi L4, L5, and S1 bilaterally.47 Furthermore exercises would be needed to strengthen her gluteus maximus in order to decrease stress at her lumbopelvic junction.40 Anticipated good results with treatment of diastasis rectus, as it was not too far from normal and again she had room for improvement with tone and strength of her lower abdominals and lumbar spine.29,32, 45,46
Lastly in order to address her bladder incontinence she would need to normalize her breathing.33,43,48 In order to normalize her breathing she would have to strengthen her weak and under used mid and lower intercostals and diaphragm. Manual therapy (manual trigger point release and thiele massage) would be used to release her tight obliques restricting movement. Furthermore cuing and education on how to improve her posture to further allow normal mechanics would be desired. Lastly the plan was to synchronize her pelvic floor and transverse abdominus with her diaphragm and intercostals.48 This would be done with verbal and manual cuing.
Bowel incontinence prognosis was fair, as she did have a palpable deficit in her sphincter.9,10 However on the bright side, there was room for improvement as her anal sphincter was rather weak.
Plan of care for this patient was to treat her once a week for a total of 16 visits over 4 months time. Once a week was chosen to allow for lifestyle changes to take place along with musculoskeletal changes for more permanent results. Furthermore research has shown 3-4 months duration an effective time to make strength changes.49,50
The therapist’s goals coincided with patient’s goals. The goals were to be met in 16 weeks. The patient’s first goal was to be able to decrease the use of the restroom for urination from 12 times a day to 8 times a day in order to complete her activities of daily living without disruption of urge and frequency. The second goal was for the patient to be able to eliminate bowel incontinence and to hold back gas in order for her to be in the community without embarrassment and discomfort. Lastly, her third goal was to be able to workout without leaking urine while running.
The therapist started by treating the muscular restrictions at her pelvic floor, specifically focusing on the left. Thiele massage and trigger point release were the manual techniques chosen to lengthen the pelvic floor musculature and restore normal physiological range of motion and function. The thiele massage technique and manual trigger point release were applied to taut bands within the pelvic floor muscles including: puborectalis, iliococcygeus and coccygeus, superficial transverse perineal and ischiocavernosus. The puborectalis on the left was addressed at day one of the examination. She was also given a bladder and bowel diary as this time. The bladder diary was used to determine the amount and frequency of urine and bowel; along with any leaks of bowel or bladder. Furthermore she was asked to record fluid intake and amount of pads used for protection of leakage. She was to record in the bladder diary for a 24-hour period of time for 3 days straight.
At day 2 of her physical therapy treatment her bladder diary revealed she was urinating often, up to 2-3 times within one hour. Furthermore, the amount she urinated was recorded in seconds and ½ of the 13 times she urinated it was less then 7 seconds of urine. Normal urination is 21 seconds (with a standard deviation of 9), interesting it is the same for all mammals from mice to elephants: “Law of Urination”.51 She was educated on how to train her bladder for urge control, and started with a goal of urinating no more then once in an hour. She was instructed to avoid the urge to urinate, progressing from 1 hour to 3 hours. She was told to do kegels when it was difficult to control the urge, furthermore to take deep breaths and wait for the urge to pass. Within the first 3 weeks she retrained her bladder to empty every 3-4 hours to meet normal frequency.
Treatments 2 through 4 were devoted to restoring normal range and mobility of her pelvic floor muscles. Furthermore adding strength to her pelvic floor muscles. Techniques again used were manual trigger point release and thiele massage; along with manual stretching, incorporating breathing techniques while working manually. In order to assist with relaxing the pelvic floor the clinician used cuing “sniff”, “flop” and “drop”. The Sniff is a light and effortless inhale. The flop is felt as the abdominal muscles relax and the diaphragm contracts and fills the upper abdomen with air. The drop is a subtle relaxation or release of the pelvic floor starting anterior and finishing posteriorly. Focus on the drop can be at the “sniff”, “flop”, and after the “flop”.42,52 Once the patient learned to relax the pelvic floor by means of manual work, breathing and imagery, then the practitioner shifted to activation of the newly lengthened muscle. At this time the practitioner cued the patient to contract from “back to front” while exhaling and then to relax the pelvic floor on the inhale. The purpose of activating the muscle is two fold. For one, the manual techniques can be painful and temporarily make the patient not want to contract, thus inhibiting the muscle. Secondarily after the release is done, they have a new lengthened and uncoordinated muscle that needs neuromuscular re-education. Focus was on symmetry left/right and anterior/posterior, along with progressing mobility and strength. The practitioner and patient worked towards levator ani strength of a 4/5, which is good strength with a lift.36 Seventy percent of the pelvic floor muscles are slow twitch, type 1 muscle fibers; leaving 30% type 2 fast twitch.7 Both fast and slow twitch fibers were therefore addressed. She was told to start by holding a kegel for 8 seconds times 10 with 4 seconds of rest in-between holds, this was to be done for 3 sets a day. Furthermore she was to perform 10 quick contractions times 10, again for 3 sets a day. The quick contractions were full contraction and full relaxation x 10.53,54,55,56 A goal of 4/5 for her levator ani was met within the first 1.5 months. Then the clinician educated the patient on neuromuscular re-education, specifically that the pelvic floor muscles need to be turned on with as many activities as possible in order for the neuromuscular re-education to carry over with her activities of daily living. The pelvic floor muscles are always supposed to be “turned on” or activated. The muscles of the pelvic floor are under involuntary control, however to train them we use voluntary and imagery. Furthermore, the pelvic floor and transverse abdominus and multifidi muscles respond prior to limb movement. 57,58 Kegels were progressed to functional movements and the patient was cued to activate levator ani muscles prior to movement. Exercises progressed to focusing on incorporating breathing with the kegel. She was also taught the “knack”, which is to do a kegel and then cough. With running she was instructed to work towards holding 10 seconds while running for 10 repetitions.
Visits 5 and 6 focused on sphincter strengthening. Cuing manual and verbally was used to strengthen the sphincter muscles. Manual work at pelvic floor muscles continued during these two visits also, along with progression of her exercises. The mobility of the sphincter was within normal limits minus the gap at 12 o’clock on her anal sphincter, secondary to episiotomy and/or tear. Either way, the gap was deemed permanent, and time was focused on strengthening. The muscle fibers of the sphincter are both type 1(slow) and type 2(fast), and the range is variable.59 Therefore, similarly to her levator ani muscles she was given a home exercise program for both muscle fiber groups. She was progressed in the same manner as her levator ani.
Visits 8 through 11 focused on transverse abdominus strengthening. She was taught how to isolate and activate her transverse abdominus using real time ultrasound imaging along with tactile and verbal cuing. When observing the transverse abdominus the curvilinear probe was placed just above the iliac crest and angled so the lateral sides of the transverse abdominus were seen wrapping around the lateral aspect of the patient. In view on imaging was also the internal and external obliques. The patient was asked to place two fingers gently on either side of her umbilicus. The clinician at this time instructed the patient to try and bring two fingers apart and to the back of her spine gently. Observation was made to assure the transverse abdominus was contracting independent of the obliques. The transverse abdominus strengthening progressed in the same manner as the levator ani and the sphincter. It progressed from the following positions: supine, sitting, standing, functional movements, breathing, running. The patient was taught how to palpate the transverse abdominus for firing and the linea alba for tension. She was instructed to progress by contracting the transverse abdominus from supine, sitting, quadruped, standing, activities of daily living and with running and breathing. Hip musculature strengthening and stretching of hip and lower back were also added to her HEP, within these exercises the levator ani, sphincter and transverse abdominus were incorporated. Hip strengthening included side-lying hip abduction, side-lying and quadruped hip external rotation, and hip extension over table (where anterior superior iliac spines would be stabilized). Furthermore, stretching included a deep squat with hip external rotation along with yoga positions: 1) prayer position, 2) warrior II, and 3) triangle. The multifidi at levels L4 –S1 was released and activated with dry needling to assist with lumbopelvic stability, by restoring ROM and strengthening the lower lumbar multifidi.25,47 The parameters on the intramuscular electrical stimulation unit(ITO ES-130) were set at 4hz for 10 minutes, with the 3 channels connected to the needles at the lumbar multifidi L4, L5, and S1 bilaterally. 47 The dry needling with the intramuscular electrical stimulation unit(ITO ES-130) was done at both visits 10 and 11.
Visits 12-14 focused on review of the above exercises and incorporating them all within her exercises and with functional movements and positioning. Patient was progressing nicely minus complaints of gas leakage.
The last two visits were focused on rectal sphincter strengthening, secondary to patient having consistent complaints of gas leakage still being a problem. The rectal balloon catheter and a 50mL syringe were used for strengthening on these last 2 visits.18 The catheter was filled to the lowest volume of air the patient was able to tolerate and the clinician cued the patient to contract as soon as sensation was felt, with a goal of responding to sensation as quick as possible (less then 1 second). Patient was highly encouraged to do sphincter squeezes throughout the day with positional changes, exercises, coughing, sneezing; in order to have the muscle be functionally strong and helpful to prevent leakage of gas.
The Patient’s Pelvic Floor Distress Inventory Score was a 12.5 at discharge, which had improved from a 132. This indicated that her pelvic floor disorders had a significantly lesser negative impact on her quality of life then prior to physical therapy.19,20
The first goal was for the patient to be able to decrease the use of the restroom for urination from 12 times a day to 8 in order to complete her activities of daily living without disruption of urge and frequency. This goal was met within the first three weeks of therapy, with strengthening of the pelvic floor and bladder retraining being the main treatments rendered within that time period. Therefore, these treatments were most likely the reasons for success of her first goal.
The second goal was for the patient to be able to eliminate bowel incontinence and to hold back gas in order for her to be in the community without embarrassment and discomfort. This goal was only partially met. The patient was no longer leaking bowel, however she was still having complaints of gas leakage with work events and at home.
Patient reported no incontinence of bowel or bladder for more than the last 4 weeks of therapy. Potentially contributing factors to not leaking were normalizing her bladder habits, increasing her levator ani, transverse abdominus, and multifidi strength; along with neuromuscular re-education to incorporate this strength with her activities of daily living (sitting, standing, squatting, running, breathing). The patient’s pelvic floor strength went from a 3/5 to a 4/5. Indicating she was able to go from a fair squeeze, with a definite lift to a good squeeze with a good lift and able to hold the lift against resistance.35 The ability to hold her kegel against resistance could have potentially contributed to not leaking with activities where gravity or weight would place resistance on the pelvic floor: standing, squatting, walking, running, breathing, lifting. Following therapy the patient was no longer classified has having diastasis rectus abdominus, the widest inter-recti distance went from 4.5cm to 2.0cm.29,30 Furthermore, the clinician’s fingers were not able to go as deep into the patient’s inter recti distance as they were at the initial visit, indicating increased tension/support to complete the “circle of integrity”.22,24 The patient’s transverse abdominus increased from a 1/5(being able to lift one foot while holding her lower back in a neutral lumbar position) to a 4/5(being able to slide bilateral heels on floor with her back in a neutral lumbar position).20 This increased support at her linea abla and transverse abdominus again potentially assisted with continence as they both assist in providing lumbopelvic stability.21,24,32,37,38 Strength at the sphincter muscles went from a 2+/5(indicating ability to hold a weak sphincter contraction with no significant closing felt at her sphincter muscles) to a 4/5(were she was able to hold a good squeeze and lift against resistance).20 Again the patient’s ability to resist weight and gravity at the sphincter would allow for increased sphincter control with activities of daily living(sitting, walking, running, breathing, lifting). The lower multifidi were activated with hip extension in supine and with ambulation. These muscles again adding to lumbopelvic stability.21,24,32,37,38 Posture was still a problem, the patient was still hinging at T8-9. Although she could easily self correct without muscular restrictions felt. Patient was able to breath with her diaphragm, mid intercostals and upper intercostals; again though it was not consistent and needed more neuromuscular re-education. Both her posture and breathing muscles allowed for normal breathing mechanics, therefore placing less pressure on her pelvic floor.33, 43,48
Lastly, her third goal was to be able to workout without leaking urine while running. This goal was met. Again most likely met for the same reasons as goal 1 and 2.
Patient still had complaints of passing gas involuntarily. It is possible she needed more neuromuscular control to break a bad habit of not trying to hold back gas while at home.
In16 weeks the patient achieved most of her treatment goals. She went from years of urgency, frequency and incontinence of her bladder to a continence of her urine in less than six months. That is significant for her quality of life. Although her postural command required effort, she was able to self-correct. The patient’s personal needs were not all met in that she was still having incontinence of flatulence at discharge. However, the writer questioned whether her gas leakage could simple be a bad habit or the sphincter muscle could still not be functionally working for her. Prior to discharge the patient was heavily educated on the importance of continuing with her exercises. It is possible that the patient just needed more practice perfecting her newly acquired skills.
If this therapist were able to treat the patient again, other forms of treatment would be incorporated including cervical and cranial alignment.60 It is possible that her sacrum could have been slightly off secondary to her multiple lumbopelvic musculoskeletal imbalances. Furthermore, even if her sacrum was aligned it is possible there was a rotatory force holding her sacrum in alignment. For example, the patient’s hip rotators were most likely constantly adjusting for stability at the sacrum to keep dural alignment from the cranium to the sacrum. The rotators would have to work harder secondary to her weak multifidi, weak transverse abdominus musculature, and lack of linea able tension. Therefore her cranium and/or cervical spine would most likely have to offset the forces created by the pelvis/sacrum musculature in order to keep dural alignment.
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