Story
36 years old woman, Mrs A, comes to physical therapy because of urinary incontinence while running and from time to time in sudden, fast movements. She has had leakage of urine since giving birth in June 2015.
Involuntary leakage of urine on effort or exertion, sneezing and coughing, without compulsory need to urinate is called stress urinary incontinence (SUI) and is the most common type of urinary incontinence in women. In exertion the muscles and connective tissue of the pelvic floor give away and the raise of abdominal pressure of the abdominal cavity overruns the pressure of the urethra causing urine to leak. According to literature the reason for this is the weakness of connective tissue and closing mechanism around urethra and low pressure in the urethra. Predisposing factors for this are for example overweight, pregnancy, childbirth and excessive smoking.
In June 2015 she had a vaginal delivery. The baby was her firstborn. For the second stage of labour she was lying in a half sitting position, knees flexed. She got epidural and nitrous oxide (“laughing gas”) as pain medication. The second stage of labour lasted for a bit over half an hour and she got an episiotomy. She does not recall any tearing of the connective tissues or muscles. After giving birth they had to remove the placenta by hand under anesthesia. Her episiotomy scar was painful and she had hard time to sit for two weeks. Otherwise the episiotomy scar healed without infection or other problems. She started to run couple of months after giving birth.
What made her come to see a pelvic floor physical therapist now, was because recently she participated an event where she had to run for two kilometers and needed to go pee in the bushes even though she had just gone to pee. She felt that if she hadn’t gone to pee in the middle of the run, she would have leaked urine. She has noticed the leakage of urine also, when doing sudden and fast movements, jumping on a trampoline, while walking and sneezing at the same time (she needs to stop to sneeze) and when she is tired.
Incontinence in sudden and fast movements has reduced when she went to see a physical therapist couple of years ago and got movements like opposite arm and leg lifts in quadruped position and doing alternate leg lifts sitting on a big gymball. Now more disturbing for her is the leakage of urine while running. Leakage of urine while running happens sporadically and varies in amount. Sometimes she does not leak at all while running and sometimes she leaks soon after starting to run.
She doesn’t smoke, she is normal weight and is in good health, no medications. As injuries, she claims that she sprained her ankles many times as a child. She hasn’t had any surgeries. She had a hormonal IUD three years after giving birth but changed it to Nuvaring (a hormonal vaginal ring) a year ago, because of dryness of mucosa in vagina. Vaginal dryness reduced after changing the contraception. Changing the contraception, didn’t change her SUI symptoms.
She works in an office and sits a lot in front of computer. She is right-handed. During her work day she drinks at least 1 liter of water and couple of cups of coffee. She urinates about every 3 hours. She has carried her baby on the left shoulder and now she carries her child on her left hip. This is a question I always ask, since this is something mothers do a lot during the child’s first years and our bodies adapt to the way we use our bodies creating possible shifts, rotations, tilts etc. accordingly. These can affect our healthy body alignments and biomechanics.
Before giving birth, she used to run 5-13km at a time, several times a week and participate in group fitness classes. Now she runs, swims, bikes, goes to the gym and does Bikram yoga.
Leakage of urine while running annoys her, since running is important type of sport for her and she would like to be able to run without incontinence.
Diane’s question:
Great description of meaningful events Mari. Does she experience any mid or low back or pelvic girdle pain or pelvic pressure in addition to her urinary leakage complaints?
Mari’s response:
She doesn’t have any other complaints.
Meaningful Complaint
Urinary incontinence while running.
Cognitive Belief
She started to run early, only couple of months after giving birth and wonders, if that could have an effect on the SUI. She had asked a doctor about running when she met a doctor 2 months after giving birth but she really didn’t get any clear answer. Doctor told that she could exercise as she feels good. Her husband and a friend advised her to just go running since she likes running. She hesitated but also thought that urinary incontinence is normal after giving birth. She has been worried that has she caused a uterine prolapse by running and now her uterus is compressing the bladder.
Diane’s comment:
So many women believe that urinary incontinence is normal after giving birth! She obviously doesn’t believe this, even though she states she does, because she keeps seeking care to eliminate it. Good for her.
Meaningful Tasks
To be able to run without incontinence.
Screening Tasks
In ISM approach, the screening tasks are chosen based on the meaningful task. Screening tasks are used to reveal if the patient’s used strategy is optimal or suboptimal. Suboptimal strategies are identified when body regions reveal poor alignment, biomechanics and/or control (A, B, C’s) for the task being screened. In an optimal strategy, urinary continence is maintained. When a suboptimal strategy is discovered, corrective manual and verbal cues are used to determine which biomechanical correction on which site of the body provides the best improvement in the task and/or symptoms. The impact of the correction on other sites is also evaluated. This helps to identify the ‘driver’ or body region requiring intervention first.
During pregnancy and delivery, the abdominal wall and pelvic floor are under a long-lasting mechanical stress. Mechanical stress with hormonal changes has an effect not only on musculoskeletal and fascial system but also on neural system. Research shows that women that have given birth have dys-synergy in activation and relaxation between abdominal muscles, pelvic floor muscles and diaphragm. It also shows, that if the dys-synergies are not corrected, they will not repair on their own but can cause dysfunction. Because Mrs A is suffering from SUI, the state of her pelvic floor muscles is examined more in detail.
Mrs A has incontinence while running so the screenings tasks chosen are the following: one leg stand and thorax rotation.
In order to know what is driving the symptoms in movement, we need to know, what is the starting point, postural alignment before the movement. Standing postural analysis gives an idea what are the alignments of the body parts in relations to each other. In order to have optimal function in movement we need optimal alignment, biomechanics and control. If the non-optimal alignments do not get better or they get worse in movement, optimal biomechanics and control cannot be achieved and this can cause stress and overloading of some tissues, joints, nerves etc. causing pain or for example incontinence.
Findings for the Standing Screen
Functional Unit #1 (FU#1 – 3rd thoracic ring to hips)
Pelvis: In standing, her pelvis is rotated to the left in the transverse plane (TPR) with congruent left intrapelvic torsion (IPT) (right innominate rotates anteriorly, left innominate rotates posteriorly, sacrum rotates to the left and nutates relative to both innominates)
Hip: Right femur is anterior relative to the right acetabulum (not centered in the acetabulum).
Thorax: 3rd ring is translated to the left and rotated to the right and the rings 4-12 are translated to the right and rotated to the left. Her right scapula is elevated and protracted.
Diane’s question:
In FU#1 which findings are congruent and which are incongruent and why is this important to note in a standing postural screen?
Mari’s response:
Her thorax from rings 4 to 12, pelvis and hip position and rotation are congruent findings (rotating the same direction) but her 3rd ring is incongruent (rotating the opposite way) with them. Incongruencies are important to note because optimal alignment is required for the optimal biomechanics, motor control and movement. By finding the incongruencies in standing postural screen, we can monitor their behavior when moving into screening tasks and movement. When looking for the drivers, and when correcting incongruencies, we reflect at the same time, what impact each correction has on the other found incongruencies, do they get corrected and aligned.
Diane’s comment:
Correct, and the driver is often at the site of the incongruency.
Functional Unit#2 (FU#2 – second thoracic ring to the cranium)
Cranium: Cranium is in right ICT, (right mastoideus forward), right temporal bone is posteriorly rotated and the left temporal bone is anteriorly rotated. Her sphenoid is also rotated to the right. These findings are congruent with each other.
Cervical spine: C2 and C7 are translated to the right and rotated to the left.
Clavicle: Left clavicle is medially translated and compressed on the medial sternoclavicular joint and riding up the manubrium.
Thorax: 1st ring is rotated to the right and 2nd thoracic ring is translated to the left and rotated to the right, sternum is rotated to the right.
Cranium torsion and cervical spine rotations are incongruent with each other. Cervical spine rotations are incongruent with the thoracic rings 1, 2, 3 and sternum rotation.
Functional Unit #3 (FU#3 – lower extremity)
Femur: Right femur in internal rotation
Tibia: Right tibia in internal rotation
Foot: Right calcaneus in eversion, right talus adducted and plantarflexed, naviculare in external rotation relative to the talus.
The rotations and positions are congruent in the right lower extremity and they are also congruent with the hip and pelvis.
One Leg Stand (OLS)
OLS evaluates intrapelvic motion control – the ability of the lower back, hips, pelvis, knee and foot to transfer load unilaterally. Activity of the pelvic floor is affected by the position of the hip (Bendova et al 2007) and pelvis (Sapsford et al 2008) so this is a good test for Mrs A suffering from SUI while running.
In order to transfer load optimally, the femoral head should stay centered both in the weight bearing leg and the flexing leg, the flexing non-weight bearing innominate should rotate posteriorly in relation to the ipsilateral sacrum (testing the active movement of the innominate relative to the sacrum), both sides of the pelvis (innominates) should move as a unit when the load is moved over the weight-bearing leg – there should not be any rotation of the innominate in relation to the sacrum on the weight-bearing leg.
Diane’s question:
What should happen to the thorax, neck, cranium, knee and foot in this task?
Mari’s response:
In OLS alignment between the foot and pelvis should stay centered – there should not be any rotations nor translations between the areas – the talus should stay centered on the top of the calcaneus. Calcaneus should stay centered. Achilles should be straight. Longitudinal arch should stay elevated. Talus, patella and center of the femur should stay in an alignment. Knee shouldn’t rotate, shift medially or laterally. Femur should stay vertical beneath the pelvic girdle, centered in the acetabulum and it should not rotate in any direction. In the thorax, neck and cranium, there shouldn’t happen any rotations nor translations.
Findings for the OLS Test
Client feels that it is easier to lift her right leg than her left leg, the following findings are for the ROLS test – lifting the left leg and standing on the right leg.
Functional Unit #1 (FU#1 – 3rd thoracic ring to hips)
Pelvis: When she lifts her left leg, her pelvis rotates more to the left and she loses the control of the right SIJ late in the task.
Hips: When lifting the left leg, the right femoral head stays anteriorly relative to right acetabulum.
Thorax: Thoracic rings 4-12 stay translated to the right/rotated left, 3rd thoracic ring further translates to the left/rotates to the right.
Driver for Unit #1: Thorax, in particular the 3rd thoracic ring.
Diane’s question:
In FU#1 there are 3 sites of impairment: pelvis, right hip and the 3rd thoracic ring. The ISM Rule of 3 suggests that once we have 3 sites of impairment, we stop and prioritize which sites are causing problems and which are compensating.
How did the noted incongruencies in your standing posture screen influence your choice of what to correct first in FU#1?
Describe the response of correcting the right hip on pelvis control and the pelvis on right hip alignment and a bit more detail about what happened to make you decide that the 3rd thoracic ring was your FU#1 driver.
Mari’s response:
My first correction was the 3rd thoracic ring because it is the area of incongruency. Aligning the 3rd thoracic ring made the task easier to do and helped the pelvis and hip alignment. Aligning the pelvis made the hip and the OLS worse. Correcting her right hip didn’t help the pelvis alignment and made the OLS worse.
Functional unit #2 (FU#2 – 2nd thoracic ring to the cranium)
Cranium: Cranium stays in right ICT
Cervical segments: C7 translates to the right and rotates to the left even more, C2 stays right translated and left rotated.
Thorax: 1st thoracic ring rotated to the right, 2nd thoracic ring further translated to the left and rotated to the right.
Driver(s) for the Functional Unit #2
Correcting C7 and the TR 2 improved the alignment of the C2 and cranium. Correcting the cranium didn’t change the TR 2 nor C7 therefore the driver is neck and thorax, in particular C7 and 2nd thoracic ring.
Functional unit #3 (FU#3 – the right lower extremity)
Tibia: Right tibia rotates more internal
Foot: Right talus adducts, calcaneus goes more into inversion, midfoot collapses
Driver for Unit #3: No driver from the FU#3
Diane’s comment:
Actually the right foot is not performing optimally in this task; therefore, the right foot is a driver for FU#3.
Summary of Functional Unit Drivers for the ROLS Task:
3rd thoracic ring correction corrects 2nd thoracic ring but makes C7 worse. C7 corrects partially 2nd and 3rd thoracic rings – best correction is to correct C7 and 2nd and 3rd thoracic ring simultaneously therefore the neck and thorax are co-drivers.
Diane’s comment:
Since Mari did not consider the right foot to be a unit #3 driver, the impact of correcting C7 and the 2nd and 3rd thoracic rings on the alignment and control of the foot in right single leg stance was not determined. For a runner, I think this would be critical to know.
Standing trunk rotation
In standing trunk rotation pelvis and thorax rotate congruently but in running pelvis rotates incongruent to the thorax.
In running, the thorax should be able to rotate equally in both directions. In left trunk rotation the left clavicula should posteriorly rotate and the right clavicula anteriorly rotate. Medial end of the clavicula should not compressed on the medial sternoclavicular joint. In left rotation the left ribs should posteriorly rotate and the right ribs should anteriorly rotate. The thoracic rings should translate to the right during left rotation (except the first ring). The first ring only rotates, it doesn’t translate.
In standing trunk rotation to the left, her pelvis should rotate to the left – right innominate to anteriorly rotate and left innominate to rotate posteriorly. Her right foot should pronate and the left foot supinate.
In the standing trunk rotation, she finds it harder to rotate to the left. The following findings are for the left trunk rotation:
Functional Unit #1 (FU#1 – 3rd thoracic ring to hips)
Thorax: 3rd thoracic ring translated even more to the left and rotated to the right incongruent to the task and is therefore of interest.
Pelvis: Pelvis stays in left rotation.
Hip: Right femur stays anterior to the acetabulum.
Driver: Thorax, in particular the 3rd thoracic ring
Functional Unit#2 (FU#2 – 2nd ring to the cranium)
Cranium: Cranium stays in the right ICT,
Cervical spine: C7 rotated to the left/translated right – C2 stays translated to the right, rotated to left.
Thorax: 1st thoracic ring rotated more to the right and 2nd thoracic ring translated even more to the left and rotated to the right. Left clavicle does not rotate posteriorly and compressed on the medial sternoclavicular joint.
Drivers: Neck and thorax, in particular C7 and 2nd thoracic ring which are rotated incongruently to each other and the TR2 is starting incongruent to the biomechanics required for this left rotation task.
Functional unit #3 (FU#3 – the right lower extremity)
No findings from the FU#3
Summary of Functional Unit Drivers for Standing Left Rotation Task
3rd thoracic ring correction corrects 2nd thoracic ring but makes C7 worse. Correcting 2nd ring corrects the 3rd ring but makes C7 worse. C7 corrects partially 2nd and 3rd thoracic rings – best correction is to correct C7 and 2nd and 3rd thoracic ring simultaneously so the neck and thorax are co-drivers. This is the same finding as that noted for the ROLS task.
Screening Tasks Summary
Relationship between drivers of all functional units for both tasks:
Left OLS: Co-drivers: Neck and thorax, in particular C7 with 2nd and 3rd thoracic ring
Left standing trunk rotation: Co-drivers: Neck and thorax in particular C7 with 2nd and 3rd thoracic ring
Further Analysis of the Drivers
Assessment of the drivers include active and passive mobility and active and passive control tests and vector analysis to see which system is causing the impaired function of the driver – visceral, articular, neural or myofascial. In vector analysis, listening techniques are used to identify the specific system vectors and the priority for treatment.
Thorax: 3rd Thoracic Ring – Further Assessment
Active Mobility: In inhale and in left trunk rotation, the 3rd thoracic ring is limited.
Passive Mobility: The passive mobility of the 3rd thoracic ring was also limited in left rotation.
Vector analysis: When attempting to correct the 3rd thoracic ring only a partial correction was possible. Therefore, there were likely articular system vectors impacting the ability of this ring to rotate to the left. However, the first vector noted on both correction and release of the 3rd thoracic ring was strong, inside the thorax and directly behind the sternum, likely the transversus thoracis or the endothoracic fascia.
Thorax: 2nd Thoracic Ring – Further Assessment
Active Mobility: Same findings as TR3
Passive Mobility and Vector analysis: Same findings as TR 3
Neck: C7 – Further Assessment
Active Mobility: C7 was limited in right rotation.
Passive Mobility: C7 was limited in right rotation passively.
Vector analysis: When attempting to correct C7, only a partial correction was possible. Therefore, there were likely articular system vectors impacting the ability of C7 to rotate to the right. However, the first vector noted on both correction and release of C7 was strong, inside the thorax and directly behind the sternum, again likely the transversus thoracis or the endothoracic fascia.
Drivers & Motor Control
Since Mrs A suffers from SUI, pelvic floor examination was done during the first visit in order to know what was the state and function of her pelvic floor muscles and connective tissues as well as their relationship to the drivers noted in the assessment above.
Diane’s comment:
Was this to address her cognitive belief or your belief that this was necessary?
Mari’s response:
Both. By assessing her pelvic floor, I could show her the difference and change in her pelvic floor function, when the drivers were corrected. Also, this way I could prove that the pelvic floor function can be changed from the above and motivate her for the physical therapy. And for my cognitive belief, as trained for “traditional” pelvic floor physical therapy”, I always check the pelvic floor function as part of the “protocol”. I also wanted to experience the change in her pelvic floor function.
Pelvic floor muscles (PFM) form the pelvic basin and they have an important role in maintaining continence. PFM, together with endopelvic fascia, support the pelvic organs, close the pelvic openings by contracting and lifting anterior and cranial/cephalad. PFM have also an important role in stabilizing the SIJ, especially in women. Continence is provided not only through PFM function but the whole body and integration of pelvic, spinal and supraspinal factors.
The first examination of the pelvic floor was done in hook lying position, when she is in the most relaxed position, in order to get a thorough image of the state of her pelvic floor muscles and connective tissues. Later on, the examination will be done in upright position and during movement, since her symptoms appear during movement in upright position. The positional findings noted in postural screen were the same in laying down.
With Mrs A in hook lying, convex real time ultrasound probe is placed suprapubically on the abdomen in transverse plane. In the ultrasound imaging, the left side of the pelvic floor is higher than the right side. While Mrs A contracts her pelvic floor, there is less lift on the left side than the right side. Left side of the pelvic floor relaxes slower than the right side.
Diane’s question:
According to Peter Dietz, transabdominal imaging is the least valid way to understand the behavior of the PFM. What is the clinical significance, if any, of the asymmetric bladder base noted at rest and the asymmetric response to a cue to contract the PFM?
Mari’s response:
Indeed, asymmetric bladder base on transabdominal imaging cannot be interpreted as for example high muscle tone on the other side (on the left side it can be for example stool in the rectum pushing the left side up), we can only say that it is asymmetric. Clinically asymmetry indicates to me that the function of the pelvic floor is not symmetric nor optimal and may influence the task and symptoms. Asymmetry needs to be explored more in detail. For that reason, I did external and internal palpation to see, what is causing the asymmetry. External and internal palpation found high muscle tone on the left side of the levator ani.
Probe in sagittal plane transabdominally, pelvic floor lift is cranial but the elevation of the bladder neck is partial.
Diane’s question:
What is the clinical significance of the bladder neck lift being partial?
Mari’s response:
According to literature, the bladder neck position should be above the pelvic floor in order for the pressure to transmit equally to the bladder and the urethra and this way lead to a simultaneous increase of urethral pressure. If there is not a good elevation of the bladder neck, it may lead to bigger pressure on the bladder than on the urethra and may lead to incontinence.
When her left rotated C7 is corrected, we can see in the ultrasound how the left side of her pelvic floor comes down and evens up with the right side.
Diane’s comment & question:
According to the principles of an ISM assessment an evaluation of the PFM would only be done IF control of the pelvis was still lost in the OLS task when the functional unit drivers were corrected. You already knew that her motor control for the pelvis was restored from your driver assessment above, so was this examination necessary? You are confirming via a direct examination what the driver analysis already told you.
Mari’s response:
We know that the motor control of the pelvis is restored, but without checking the pelvic floor, we do not know is she able to contract all the pelvic floor muscles and on both sides, and what is the strength of the muscles and is the ability to contract and strength enough for continence. According to research pelvic floor strength decreases after delivery, more than 30% of women are not able to correctly contract their pelvic floor muscles during their first visit to physical therapist and 50% of women get a neurogenic and structural trauma to their pelvic floor during vaginal birth. Mrs A also had episiotomy during the birth and episiotomy is often reported to worsen post-partum pelvic floor dysfunction. Several muscles of the pelvic floor have a role in continence, so I saw it necessary to determine the whole state of her pelvic floor, in order to see is she able to contract her pelvic floor muscles correctly, symmetrically and does she have the needed strength in her pelvic floor muscles for continence. Especially I was interested in confirming that she is able to activate the external urethral sphincter, which is in main responsibility to close the urethra. This can be palpated only internally because of its location. Internal examination (see later in this report) revealed that the image she was using to close her urethra, didn’t give her the best activation of the urethral sphincter.
Diane’s question:
What biologically plausible mechanism could explain how changing the alignment of C7 could affect the resting behavior of the left and right sides of the pelvic floor muscles?
Mari’s response:
In my mind it has to be through dura and fascial connections. Correcting right translated and left rotated C7 has the potential to reduce the tension through the lower cord of the brachiplexus and thus the perineurium and dura.
Diane’s question:
Can you think of a neurodynamic test that you could have done to test this hypothesis?
Mari’s response:
Monitor of the position of the coccyx in standing, correct C7 and see if the position of the coccyx changes. Upper limb neural test – if it pulls the coccyx.
External palpation of the pelvic floor: Increased tone and tenderness of the levator ani on the left side, compared to the right side. The levator ani is the deep layer of the pelvic floor muscles and it supports the vagina and the pelvic organs. There is weak contraction of the superficial bulbocavernosus muscle on the left side, compared to the right side. The strength and function of the bulbocavernosus muscle is important since it supports the deeper urethral sphincter muscles. Correcting the right rotated 2nd thoracic ring helped Mrs A to produce a stronger contraction of the left bulbospongiosus and relieved slightly the increased tone in the levator ani on the left side. But by correcting her left rotated C7, her levator ani on the left side relaxes and isn’t tender anymore.
Diane’s comment:
The value of this external examination is more cognitive for the patient than essential for you to plan treatment. Why?
Mari’s response:
External palpation helped Mrs A to feel and experience the difference in her pelvic floor muscles when the drivers were corrected. This helps her to realize that what is influencing on her incontinence and motivates her to be an active actor in her rehabilitation.
Intravaginal palpation in hook lying position (examination was done with a right index finger while the left hand and arm was holding Mrs A’s knees together in order to get her in a most relaxed and comfortable position): On the left side of the levator ani, muscle tone is higher than on the right side and the relaxation is slower than on the right side. The strength of the pelvic floor is Oxford scale (Scale 0-5) is 3: “Moderate contraction, felt like an increase in intravaginal pressure, which compresses the fingers of the examiner with small cranial elevation of the vaginal wall” in levator ani. When palpating the middle layer of the pelvic floor muscles around the urethra, and asking her to contract her pelvic floor, there is a weak contraction of the urethral sphincter and weak cranial elevation of the bladder neck on both sides but weaker on the left side. The image she uses in contracting her pelvic floor muscles is holding pee, which creates a weak contraction but hardly any cranial elevation to the bladder neck. In coughing there is a descent of the bladder neck. When she is asked to lift her clitoris, there is more cranial elevation on the bladder neck.
When correcting the 2nd thoracic ring, the muscle contraction around the urethra is stronger and the cranial elevation of the bladder neck is better. She also feels that the contraction of her pelvic floor is better with the 2nd thoracic ring correction. Also, when the 2nd thoracic ring is corrected and she coughs, the bladder neck descent is less than without the correction.
Diane’s question:
What grade of strength did the pelvic floor contraction increase to with the drivers corrected? Was there an endurance deficit noted? These questions relate to your initial treatment session below and why you chose to have her ‘train her pelvic floor muscles because of an endurance deficit. I can’t find where in this report you note an endurance deficit of the PFM.
Mari’s response:
When I corrected the drivers, it improved her ability to activate the muscles but because she hadn’t used them for a long time, there was an endurance deficit.
Diane’s comment:
The above are more findings that confirm that Mrs. A’s PFM behavior (all 3 layers) is in relationship to the alignment of C7 and TR2. In my opinion, this entire pelvic floor muscle assessment would not be necessary to plan treatment BUT may be necessary depending on?
Mari’s response:
Pelvic floor examination is needed, if the pelvis control is not restored in the meaningful task when the drivers are corrected.
Diane’s comment:
However, pelvic control was restored when her neck and thorax alignment was corrected, so I still don’t think you needed to do an examination of her pelvic floor – at least this is what the ISM examination for this patient suggests. It may be necessary to address a cognitive belief – and that may be either hers or yours!
Mari’s comment:
You may be right but I have hard time to brake my habits.
In standing when co-correcting the C7 and her upper thorax, she found it easier to contract her pelvic floor.
Diane’s question:
Did you do an internal exam in standing or was this a subjective report?
Mari’s response:
She felt that it was easier to lift and in perineal ultrasound in standing, the elevation of the pelvic floor was higher.
Hypothesis
When thinking about the hypothesis behind C7 and thoracic rings driving the PFM muscles, cervical spine and thorax are linked to pelvic floor through perineurium, dura and fascial structures. Left side of the pelvic floor was hypertonic likely due to multiple mechanisms. What was clear correcting C7 and upper thorax had a positive impact on her pelvic floor function.
Treatment
Release
In releasing the intra-thoracic vectors of C7 and upper thorax (TR 2 & 3) “ring stack and breathe”- technique was used. Following this, neural vectors were found in left subclavius and left pectoralis minor, which were also released with “release with awareness”- and a myofascial friction-stretch technique.
Following this release articular system vectors were noted on:
- C7 inferior glide right z joint
- TR 2 & TR3 inferior glide left z joint and inferior glide posterior roll left CT joint
These joints were all mobilized with vector specific G4 4+ techniques.
Align
Cues for alignment and home practice were given such as: Think about growing tall (lengthen the neck and tuck in the chin slightly), think about both clavicles opening to the sides, shoulders open to the sides (but not pulled back). Breath into the upper chest for 10 times. This was done standing and also on a 90 cm long Pilates roller, on which she could lay in hook lying position, arms open on the sides to get more stretch on the upper thorax.
Connect
With better alignment, the motor control strategy for C7, and the upper thorax was restored therefore no specific muscle cue was required.
Move
In standing, keep the image of growing tall, to align C7 and the upper thorax and contract your pelvic floor muscles for 5 seconds, relax for 5 seconds, repeat 5-10 times, three times a day.
Aim was to hold the pelvic floor contraction for 10 seconds, 10 times, three sets a day and by doing this, to build up the strength endurance of her pelvic floor muscles.
Treatment of the cognitive belief
Mrs A cognitive belief was that she started to run too early and was worried that by starting to run she had caused herself a uterine prolapse. We talked about this and she mentioned that the symptoms hadn’t gotten worse during the past year, so running hadn’t worsened her symptoms. We also placed a convex realtime ultrasound probe sagittal on her pelvic floor on the perineal body while standing and I could show her that her uterus was nicely placed – there was no uterine prolapse. This made her feel relieved.
Followup treatment sessions
We met six times. Incontinence issues were resolved after the second visit. We continued to work on the tone of the muscles on the right side of the neck and upper chest. We also went through how to carry her child more in ergonomic matter. She felt that she could maintain her pelvic floor contraction longer so I gave her longer holds to build up the endurance of her pelvic floor muscles.
As she didn’t experience incontinence while running, she started to run longer distances like from 7 to 10 kilometers. She had noted that she had been contracting the pelvic floor since she started to run after giving birth. She was really scared to leak, so she contracted all the time. Now she had stopped it, since she had more trust in the function of her pelvic floor.
When she started to run longer distances, she started to experience shin splint symptoms pain on her right shin and we continued to work in this problem during the visits.
Diane’s comment:
Excellent report Kelly.
Skills Demonstration
Synopsis of Video Case Study:
This synopsis is for the following videos which are not the same person as the report.
Story
42 years old man, who has been unable to do push-ups since a right shoulder injury and operation. During an ice hockey practice in January 2016, he hit a guy, flew and fell on his right shoulder. He got an acromioclavicular joint luxation and ruptures of coracoacromial- and trapezoid ligaments. Both of these ligaments were replaced with Tiger- and FiberWires. Attachments were on the right processus coracoideus and clavicula. He has had a brain surgery (right frontal lobe) in June 2014. He feels often pressure in his head, has headaches and left ear feels “locked”. He works as a software engineer.
Meaningful complaint
Inability to do a push-ups due to right shoulder “cracking”/”clunking”, getting irritated, feeling “swollen” and painful.
Cognitive belief
He believes that the wire that was put between the bones to replace the ligaments, the elasticity of the AC-joint is gone and something gives in now. He is worried that he is damaging the bones or the shoulder somehow. The “clunking” irritates the shoulder and he feels it is getting swollen and heavy. It saddens him that he cannot do push-ups. They were was one of his favorite movements.
Meaningful task
Push-ups.
Screening task
Bilateral arm elevation was chosen as a screening task, since already in a standing bilateral arm elevation he loses the optimal alignment of his cranium, neck and right shoulder girdle. This sub-optimal alignment in a weight bearing starting position (push-up position on the floor legs straight or knees bend) cause him immediate pain in his right shoulder when initiating the movement.
Relevant Findings for the Standing Postural Screen
Functional Unit#2 (FU#2 – second thoracic ring to the cranium)
Cranium: Cranium is in right intra cranial torsion, right temporal bone is posteriorly rotated and the left temporal bone is anteriorly rotated. His sphenoid is rotated to the left. These findings are incongruent with each other.
Cervical spine: Rotated to the left.
Clavicle: Right clavicle is in anterior rotation and compressed into sternum, left clavicle is in posterior rotation
Thorax: 1st ring rotated to the left and 2nd thoracic ring is translated to the right and rotated to the left, sternum is rotated to the left.
Relevant Findings for the bilateral arm elevation
Functional unit #2 (FU#2 – 2nd thoracic ring to the cranium)
Cranium: Cranium moves more into right ICT
Cervical segments: C2 and C7 translates to the right and rotates to the left even more.
Clavicle: Doesn’t rotate posteriorly, lateral end of clavicle is pressed down.
Thorax: 1st thoracic ring rotates to the left, 2nd thoracic ring further translates to the right and rotates to the left.
Correcting cranium (both the sphenoid and the ICT which are incongruent) improved the position of the second thoracic ring (video#2); however, correcting both the cranium and the right clavicle gives the best result in correcting the findings and the screening task.
Driver(s) for the Functional Unit #2: Primary driver cranial (RICT/L sphenoid), secondary right shoulder girdle (clavicle)
Further Assessment of the Drivers and the Vectors
Cranial vectors were:
- right posterior cerebellar tentorium (myofascial) (video #3) and the left anterior cerebellar tentorium (video # 4),
- superior head of the lateral pterygoid muscle (neural), right m rectus capitis posterior major and minor (neural), AO-joint (articular), right sternocleidomastoideus (neural) and m longissimus capitis (neural).
Right clavicle vectors were the right upper part of m pectoralis major and m coracobrachialis (neural).
Treatment
Release
Cranial: Drain the cranial sinuses in the cerebellar tentorium first (videos #3 & 4) Neural vectors were released with “release with awareness” and myofascial friction-stretch technique (m. sternocleidomastoideus). AO joint was mobilized with vector specific G4 4+ technique.
Right clavicle: right upper part of m pectoralis
Align
Laying down, tucking the chin a bit down, slightly compressing the second thoracic ring on the right, open the right arm on the side – bring it to stretch and breath into your upper chest.
Connect
No specific muscle cue required.
Move
For maintaining release of the pectoral m: Push-up against the wall, tug your chin a bit in and think about your clavicles wide on the sides.
Update in August 2020
During the summer of 2020, this patient has been working on strengthening his shoulder girdle and upper back muscles at a gym while maintaining the alignment cues (“tuck your chin a bit in and think about your clavicles wide on the sides”). Now he is able to do a push up against a table his body at 60-degree angle compared to the floor, without right shoulder “cracking”, getting irritated and painful. The pressure feeling in his head, headaches and left ear “locking” has reduced significantly. He does not have these feelings anymore even weekly, whereas before it was daily.
Case Study Author
Mari Camut
CoreFysio Mari Camut
ISM Series Graduate ISM Certified Practitioner
Laajalahdentie 20, Helsinki, Finland
Rummunlyöjänkatu 3, 02600 Espoo
Annankatu 32, 00100 Helsinki
Rummunlyöjänkatu 3, 02600 Espoo
Annankatu 32, 00100 Helsinki
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