Mr. B. first presented to clinic on January 9th, 2017 for his initial assessment and treatment. He is a resident of Chilliwack, BC and chose to connect with the clinic after searching online for men’s pelvic health treatment. The following is a summary of his story that was gathered during his assessment in clinic.
Mr. B. described a long standing tendency to grip and hold his abdominal muscles throughout the day which began as a strategy to reduce the appearance of a large “tummy”. He described being conscious of this appearance and the use of this gripping strategy for the past 12 years. Mr. B. is a busy father of two (a 2-year-old and a 14-year-old) and works as a registered massage therapist. Mr. B. re-counted a meaningful experience in his past that he feels contributed to his current experience of pelvic pain and dysfunction. Years ago Mr. B. remembers being very stressed balancing massage therapy school and family responsibilities while at the same time dealing with the unexpected death of a close friend. He remembers taking up pumpkin carving in his garage as a cathartic release of stress and anxiety. He noted that while sitting and carving pumpkins he would regularly feel the urge to urinate but would use his abdominal gripping strategy “sucking in his tummy” to reduce the urge to void for long periods of time. Overtime, he began to use this gripping strategy to avoid urination throughout the day. Over the following 2-3 years, Mr. B. experienced urinary symptoms including urinary urgency and frequency, nocturia, post-micturition dribble, penile irritation, penile spasms and pelvic girdle pain (PGP). Last year, after being unsatisfied practicing at a number of massage therapy clinics, Mr. B. took on the task of opening his own practice. He noted that this move increased his stress and anxiety and caused a gradual worsening of his urinary symptoms. In March of 2016, Mr. B. was involved in a motor-vehicle accident that resulted in the development of right arm and hand weakness and paraesthesia. He had x-rays and an MRI of his cervical spine to investigate potential injury to the neck secondary to his arm symptoms. The MRI identified a posterior disc protrusion that indented the anterior thecal sac and contacted the spinal cord at the level of C5/6. There was also a left posterolateral disc protrusion causing narrowing of the left intervertebral foramen at the level of C6/7. He sought out treatment for his injuries and has been seeing a physiotherapist, chiropractor and massage therapist in Chilliwack for his injuries stemming from the accident.
In Mid-November of 2016, his symptoms took a turn for the worse. He began coughing and sneezing due to a cold, this stress and strain caused him to experience diaphragm and abdominal spasms that extended from his navel to his pubic bone. Mr. B. also noticed that sitting at work and while pumpkin carving would aggravate his PGP. At the time of his first appointment Mr. B. had been making efforts to improve his overall health and wellbeing. He began a kettlebell exercise routine, and started seeing a clinical psychologist in addition to his physiotherapist, chiropractor and massage therapist. He noted that despite all of this, his urinary symptoms and PGP had not improved. At this point, he was not able to sleep through the night due to his nocturia causing him to wake every 1.5-2 hours to void. He also noticed that doing his own myofascial release of his external obliques offered some relief of his PGP, however he couldn’t achieve complete relief despite his efforts. His goals for physiotherapy were to improve his PGP, reduce his urinary symptoms and discover how his urinary function could be related to his history.
At his initial assessment, Mr. B. noted that he had bilateral PGP felt along his perineum that radiated into the testicles and penis. He also had urinary symptoms including low urine flow, post-micturition penile irritation, penile spasm, and urinary frequency/urgency and nocturia.
Based on Mr. B.’s story, standing and sitting were identified as his meaningful tasks. Standing was chosen because it is a functional position for male urination and sitting was noted by Mr. B. as an aggravating posture for his pain.
Mr. B. had a long history of urinary symptoms before he came in for treatment. As such, he had developed a cognitive belief that his pelvic floor was the culprit for his urinary symptoms and pelvic girdle pain. Before his initial assessment, he had done significant background research into the likely pelvic floor muscles that were causing his urinary symptoms. He began a stretching routine that he found on a pelvic floor physiotherapy website and did his own abdominal wall release work. This offered some relief but he was convinced that his pelvic floor muscles needed a specific and local release because he was still experiencing significant PGP and urinary symptoms.
Mr. B. also had an emotional component to his presentation that was centered around his abdominal wall gripping strategy. He was using this strategy to cope with anxiety, stress and frustration. He believed that these emotions were contributing to his pain and urinary symptoms.
Based on the meaningful tasks that were identified (standing and sitting), two screening tasks were chosen; the standing postural screen and the squat. The ISM approach was used to find the drivers that were responsible for producing non-optimal movement and neuromotor strategies for function. The screening tasks chosen were as follows:
Standing postural screen
The standing postural screen was important for Mr. B. as it was the body posture that he assumed while voiding urine. In 2007, Hodges P.W. et al. found that pelvic floor muscle activity was modulated by the abdominal wall muscles in quiet standing. They observed six female and one male subject’s pelvic floors in standing using surface EMG. They found that measures of intra-abdominal pressure recordings (using gastric pressure sensors and anal pressure balloons) were associated with changes in EMG recordings of the pelvic floor. Moreover, there were larger changes in the EMG recordings on expiration indicating that the action of the abdominal wall muscles impacts resting tone of the pelvic floor for the task of breathing while standing. From the findings of this study it is plausible that standing thorax and pelvic posture may impact the resting tone of the pelvic floor via the function of the abdominal wall muscles in breathing (particularly the external and internal obliques and diaphragm). If there is non-optimal alignment of the thorax or pelvis in standing there may be altered neuromuscular activation of the diaphragm and abdominal wall. This could result in changes in pelvic floor muscle tone in standing which may alter urinary function.
There were no reported symptoms in standing when assessed. For optimal alignment in standing, there should be neutral rotation of the cranium, there should be no side-flexion or rotation of the neck when the gaze is straight ahead, there should be no rotation or side-flexion of the thorax, normal cervical and lumbar lordosis and thoracic kyphosis should be maintained. There should be no intra-pelvic torsion (IPT) or transverse plane rotation (TPR) of the pelvis, the sacrum should remain nutated relative to both innominates, and the femoral head should be centered in the acetabulum bilaterally. On assessment of Mr. B.’s standing posture, there was an intracranial torsion to the right (ICT R), his 5th cervical vertebrae was side-flexed and rotated to the left, his ninth thoracic ring was translated left, rotated right, his pelvis was rotated in the transverse plane to the right (TPR R), his left SI joint was unlocked in standing and his left femoral head was forward (congruent with his TPR R). The impact of these areas of FLT were determined in order to find drivers for the standing task because this would affect neuromuscular function of the pelvic floor.
Correction of the cranium partially unwound the TPR of pelvis and improved control of the left SI joint. It also allowed the left femoral head to seat, however, there was still failed load transfer (FLT) of the ninth thoracic ring. Correcting the ninth thoracic ring did not improve the pelvis, hip or cranium, nor did it improve control of the left SI joint. Cueing Mr. B. to stack and align his ninth thoracic ring and offering a manual cranial correction produced a full unwinding of the R TPR of the pelvis and best overall alignment in standing. Because the cranium produced the greatest overall change in areas of FLT it was considered the primary driver. The ninth thoracic ring contributed a lesser yet significant improvement to standing postural alignment and was thus considered the secondary driver for his standing task.
Standing Task Drivers: Primary driver: Cranium. Secondary driver: 9th thoracic ring.
Neuromotor patterns of the pelvic floor:
Symptoms of urinary frequency/urgency, post-micturition penile irritation and nocturia are sometimes related to the ability to the pelvic floor to close and open the urethra. Stratford et al. (2010) validated the use of transperineal ultrasound imaging as a measure to assess the ability of the bulbospongiosus and external urethral sphincter to maintain the continence mechanism. In order to determine the impact of whole body alignment on Mr. B.’s ability to recruit these muscles, ultrasound imaging was used to record activity of the bulbospongiosus and external urethral sphincters with and without the driver corrections that were found in standing. In supine lying, there were the same areas of FLT as in standing. Mr. B. was asked to perform a pelvic floor contraction, he noted the feeling of spasm and weakness which was reflected on ultrasound. The cranium was corrected and there was a significant improvement in the experience of perineal spasm and his ability to maintain the bulbospongiosus contraction was observed (Video of this provided – transperineal US of PF).
The deep squat was used to assess early, middle and late stage strategies for moving into and out of a sitting posture.
During an optimal squat there should be no thoracic ring shifts, the lumbar spine should remain neutral with preservation of the lumbar lordosis, there should be no pelvic TPR or IPT and the sacrum should remain nutated relative to the innominates. The femoral head should seat (remain centered) in the socket of the acetabulum bilaterally, the neck may extend without side-flexion or rotation of the cervical vertebrae as the individual’s gaze may stay looking forward during the squat. The occiput may posteriorly rotate (anterior glide of the convex surface of the occiput) on the atlas bilaterally to maintain forward looking gaze, and there should be no intracranial torsion during the movement – the temporal bones, sphenoid and occiput should remain neutral.
During Mr. B.’s squat, the right ICT got worse early in the task, the C5 remained side-flexed and rotated left, the ninth thoracic ring translated further to the left, the pelvis remained in a right TPR, the left SI joint remained unlocked, and the left femoral head remained anterior.
Correction of the cranium improved the right TPR in the pelvis and it allowed the left femoral head to seat in the squat. The left SI joint began well controlled but unlocked late in the task. The ninth thoracic ring still translated left with the cranium corrected. With the knowledge that the cranium improves the pelvis and hip but not the ninth thoracic ring and that correcting the ninth thoracic ring did not improve the cranium in standing a co-correction of the cranium and ninth thoracic ring was done to see if adding a ninth thoracic ring correction would improve late stage left SI joint control. With a correction of the cranium and alignment cues to stack the ninth thoracic ring, control of the left SI joint was restored in the late stage of the squat. Because the cranium improved most areas of FLT and improved control of the left SI joint for the majority of the task, it was considered the primary driver, the ninth thoracic ring correction offered improved control to the pelvis late in the squat so it was considered the secondary driver.
Squat task drivers: Primary driver: cranium; Secondary driver: thoracic ring 9.
Vector analysis of the cranium was done to determine the underlying system impairment for the driver using a correct, release and listen technique. When feeling the right ICT, there was a right rotation of the occiput, the right temporal bone was posteriorly rotated, the left temporal bone was anteriorly rotated and the sphenoid was right rotated in the transverse plane
Correction of this right ICT was easiest with a de-rotation (to neutral) of the occiput on C1 and then gentle de-rotation of the temporal bones. The sphenoid was observed (via position of the orbits) to follow the temporal bones back to neutral rotation. Letting this correction go, there was first an immediate rotation of the occiput to the right followed by the temporal bones, left anterior and right posterior. There was a long slow posterior vector felt down along the spine extending to the sacrum. This was felt to be a dural vector and a neural system impairment.
Performing a vector analysis of the ninth thoracic ring using the correct, release and listen technique revealed a drawing of the left 9th rib forward and into anterior rotation and then a short anterior and inward tip, this was felt to be a neural system impairment causing overactivation of the left external oblique and left anterior portion of the diaphragm. Overactivation of primary muscles of respiration made sense with Mr. B.’s story that included a long history of breath holding and abdominal wall gripping.
During the initial assessment, Mr. B. was educated about the connection between the cranium, thorax and pelvic floor. He was unable to move beyond his cognitive belief that his pelvic floor was the culprit because of his own research findings previous to his initial assessment. It was determined that his cognitive belief was a barrier to treatment during the first appointment. To remove this belief, a physical assessment of the external pelvic floor was conducted. Palpation of the first layer of the pelvic floor was done to locate trigger points and identify their referral points to the tip of the penis and testicles. Mr. B. was instructed to practice manually stacking his ninth thoracic ring while verbal cues to create space behind the skull and elongate the spine were used to correct the cranium. Mr. B. was then able to feel a “release” of tension in his pelvic floor and specifically helped to create a release of trigger points in the bulbospongiosus and transverse perineal muscles. Having Mr. B. feel a change in his pelvic floor tone by correcting his cranial and thorax drivers helped him change his cognitive beliefs about his pelvic floor.
During his second treatment session, Mr. B. was ready to further explore the connection between the cranium and thorax and his pelvic floor. During this session, the RACM treatment model was used:
R: Primary Driver: Cranium – unwind the cranial torsion with the patient in crook-lying and with the pelvis in neutral resting position and wait for a dural vector release, then take the pelvis into rotation by letting the knees drop to the left and wait at the point of further tension. Once a release is felt, take the knees further into the release until no resistance is felt to the cranial correction. Secondary driver: Stretch with Awareness release of the overactive fascicle of the left external oblique to the left ninth rib of the ninth thoracic ring and a Release with Awareness of the anterior fibres of the diaphragm on the left.
A: Alignment cues were given for the cranium. Because the dural vector felt like a shortening from the occiput down to the sacrum, alignment cues were to elongate and create space behind the skull and take that length toward the ceiling feeling length all the way down to the tailbone. There was also a cue to breath laterally into his low ribs and allow space to arise between the intercostal spaces above and below the ninth thoracic ring. An alignment cue incorporating breath was especially important because Mr. B.’s story included a component of gripping and holding of his abdominal wall that was related to poor breathing patterns.
C: Correcting the ninth thoracic ring improved control of the left SI joint in the squat task so no specific connect cues were needed to control the pelvis.
When the cranium was corrected Mr. B. was able to relax his pelvic floor, and connect to his external urethral sphincter and bulbospongiosus by thinking about “shortening the penis”. He was able to hold this activation strongly, without spasm and without reported fatigue once his pelvic floor was able to relax fully.
M: Using the above alignment cues in standing (while voiding urine) and in the squat/sitting task.
During the following treatment sessions, Mr. B. was able to let his overactive pelvic floor muscles relax by practicing his alignment cues in standing and supine while incorporating lateral costal and belly breathing. Once Mr. B. was able to keep the pelvic floor relaxed, he experienced improved ability to void his bladder without penile irritation, he was also able to return to sleeping through the night without having to wake to void urine. Mr. B. was instructed to practice keeping cranial and thorax alignment when sitting at home while carving pumpkins and while at work. Mr. B. has just had his 7th treatment session. At this time, he is still working on maintaining optimal sitting posture. He experiences occasional flares of his penile pain when he sits for prolonged periods of time. His thorax alignment is better in his standing and squatting task; however, he is consistently having to cue alignment of his cranium to improve his PGP symptoms and occasional flare-ups of penile irritation. He also mentioned that he was still struggling with aggravation of arm paraesthesia and muscle twitching after doing arm movements over his treatment table at work and when holding his cellphone.
On assessment, his arm was taken into median and radial nerve tension positions as well as his cellphone holding posture. These produced symptoms of muscle twitching that he described as fasciculations. His cranial right ICT and his left side-flexed/rotated C5 got worse with wrist extension. Mr. B.’s thorax was better aligned in standing and sitting. His C5 was difficult to correct potentially because of the cervical disc injury and made no change to the arm movement task. The cranial correction produced only a small change to the experience of paraesthesia and twitching into the arm and did not improve alignment of his C5. It is likely that a co-correction of the cranium and C5 would be needed to produce a full unwinding of the dural vector causing both the FLT at the cranium and C5. In an ideal situation, 2 therapists would be present to co-correct the drivers and assess the response in the meaningful task. However in lieu of a second therapist, an alternate method was used to test the hypothesis that the dural tension between the cranium and C5 was causing nerve tension down the right arm. The cranium was corrected and it was taken into left rotation in line with C5. This was thought to unwind the dura mater between the occiput and the C6 nerve root (exiting through the intervertebral foramen at C5/6). Since this correction made the greatest change to the arm movement task, it is likely that there is a secondary driver (C5) and restoring proper alignment to both areas of FLT will be necessary to improve function in the right arm and prevent recurrence of the cranial torsion.
At the end of the last session, Mr. B. was left with a supine lying cranial alignment exercise to practice with arm movement into the positions of nerve tension that we explored during the session. He was able to find a reduction in symptoms using cues to create space behind the neck and reach the back of the head long. At his next session, we will explore control cues for C5 with integration of his cranial alignment cues for his right arm movement tasks.
As Mr. B.’s story continues to unfold there has been a continual change in his symptoms and areas of FLT. Some areas of FLT have improved (his 9th ring shift, his pelvic torsion, SI control and hip alignment) and others have remained present (his cranium and C5). As the layers of dysfunction in his body change, different drivers arise and need to be addressed. As his sessions continue, the focus on improving alignment, biomechanics and control of the cranium and C5 will lead to integration into sitting and standing tasks to restore function and resolve his remaining persistent symptoms of PGP and penile irritation.