Lending voice to whispered disease

It is estimated 40 per cent of men and women will experience pelvic floor disorder at some point in their lives.

It is estimated 40 per cent of men and women will experience pelvic floor disorder at some point in their lives. Despite this fact, most people will suffer through it in silence – thus the term, whispered disease. 

Five good breaths, four times a day; hand over chest does not move; slow, deep inhalations and exhalations.
3D lunge frontal plane.
3D lunge sagittal plane
3D lunge transverse plane Advertisement

Pelvic floor disorders occur when ligaments and pelvic structures no longer support organs like the uterus, vagina, bladder and prostate. This condition is more common as people age, mainly because of decreased movement and improper breathing (chest and shallow breathing, as opposed to abdominal deep breathing). One early cause of pelvic floor weakness (many patients will show no signs of incontinence) is pelvic instability. Understanding what questions to ask, how to test and diagnose for pelvic instability and pelvic weakness, and then treat it is key to helping patients become active again.

Patients with pelvic floor disorder typically have a history of pelvic or low back pain. Later symptoms will include urinary incontinence, urinary leakage, frequent urination, a prolapsed uterus among women, which is when the pelvic organs may bulge out of the vagina. Aside from the physical effects, these conditions can have serious psychosocial consequences for people as activities are withdrawn and relationships can be affected. Worst of all, these symptoms are often just coped with and dismissed as a normal sign of aging. 

There are a number of options for managing pelvic floor disorder, including medications like anticholinergic drugs that block the action of a chemical messenger acetylcholine.  The most common option for many, unfortunately, is withdrawal – simply refraining from many activities and wearing a protective garment.

It is important to help patients realize it is not necessary to live with this discomfort, and to consider chiropractic as their  best non-surgical option. Nearly 200,000 women undergo pelvic organ prolapse reconstructive surgery annually, with a third of the surgeries representing repeated procedures. As chiropractors, we are perfectly positioned to identify early signs of pelvic floor dysfunction, even before symptoms of incontinence have started, and correct it through better nerve function, biomechanics and muscle strength.

It is important to ask questions to learn if your patients have any symptoms. Symptoms would indicate they have had the condition for some time. Multiple vaginal births and C-sections are risk factors for women. Other risk factors – for both men and women – include past fall on the hips, car accident, disuse atrophy, even as mild as poor gait can lead to pelvic floor weakness. Other causes include pelvic instability, nerve entrapment and poor motor control.

Because pelvic instability will precede incontinence, testing for it can help with early diagnosis and prevent the whispered disease from ever occurring. Instability is caused by weakness in the ligaments and/or muscles that stabilize the pelvic joints.

Myth about Kegel exercise
Look at the function of the pelvic floor. Have you ever noticed that bladder control in children occurs concurrently and coincidentally when they begin learning how to walk? Two conclusions can be drawn from this. First, the actions of muscles during walking helps to strengthen the pelvic floor, so training the pelvic floor must occur in three dimensions (children move in all three planes). Second, the pelvic floor reacts to loading from gravity while trying to stabilize the three dimensional “wobble” of the pelvis and the trunk. The pelvic muscles integrate gravity with ground reaction forces and this happens subconsciously. Thus, conscious exercises like Kegels are not the best way to strengthen the subconscious reactive muscle of the pelvic floor. 

Aging muscles
As people age, they become less effective against gravity and ground reactions forces. One reason for this is the fact people are moving less and sitting more as they age. Evidence has shown that after any length of bed rest there is a significant increase in urinary incontinence. In other words, those that are strong and healthy develop incontinence after prescribed post-surgery bed rest. This observation was pointed out in the paper, Problems Due to Hospitalization, Merck Manual, 2009. 

As mentioned earlier, the pelvic floor strengthens with three-dimensional movements. Even runners and walkers who exercise regularly need to move through all the planes to help prevent incontinence. Sports that move through all planes, like tennis and basketball, benefit people by moving in the transverse plane. This twisting (transverse plane motion) engages the pelvic floor as it attempts to control the pelvic movement.

Let’s take advantage of our understanding of the function of the pelvic floor to create a program for this whispered disease.

Assessing patients
Some of the questions to ask when assessing patients are:

• How long have you had a problem with incontinence?
• How many times do you leak urine each day?
• Do you wear protective garments in case of accidents? How often do you wear them?
• Is it harder to control your urine when you cough, sneeze, strain or laugh?
• Is it harder to control your urine when you run, jump or walk?
• Are you constipated? For how long have you been constipated?
• Have you tried pelvic floor exercises (Kegels)? Do they help?
• What procedures, surgeries or injuries have you had? Have you fallen, had a car accident before?
• For female patients, you will ask if they’ve had multiple births. Were they C-section or vaginal births?
• Any bed rest and for how long?
• Do you have any other symptoms?

Exam
Perform muscle test with no SI (Sacro-Illiac) belt, then with an SI belt. Test for pelvic instability by testing the main supporting muscles of the pelvis. If muscles that are weak now test strong, then an SI belt will be prescribed to be worn.  The SI belt assists the body by stabilizing the SI joints and allowing the ligaments to heal. Exercises still need to be done regularly to be able to strengthen beyond the belt.

This testing would indicate a weak anchor, not a weak muscle, and therefore strengthening would be directed toward muscles that help stabilize the pelvic ligaments. According to Dr. David Leaf, a chiropractor and applied kinesiology expert: “To shorten a ligament you must strengthen the muscles that cross the ligament.”  In the case of the pelvis, gluteus maximus would be a key muscle to strengthen as it crosses the SI joint.

The diagnosis will be pelvic instability with recommendations for chiropractic, a strengthening program and to wear the belt daily for around six weeks. 

Pelvic instability can lead to pelvic floor disorder – anatomy and function say it all. The pelvic floor attaches anterior to the pubic symphysis, lateral to a fibrous attachment from the oburator internus and posterior to the coccyx and ischial spine. Part of the wall of the pelvic floor is made up of the oburator internus and piriformis. Fibers from short adductors also have attachments to the pelvic floor. 

The function of the pelvic floor is to support the pelvic viscera, resist any increase in intra-pelvic pressure rising from straining, like when coughing, and to support core strength. Think of the core like a drum, where the top is formed by the diaphragm, front and sides by abdominals, and the back by QL/erectors, then the bottom of the drum is the pelvic floor. For a proper core to be engaged there can be no leaks in the drum, therefore the pelvic floor is called upon anytime the core is. Thus the pelvic floor resists anytime the intrabdomial pressure is increased and stops evacuation from the urinary tract. It is why leaking when laughing, coughing and sneezing can indicate urinary incontinence. 

Muscle testing
An understanding of proper muscle testing is necessary and required for this diagnosis. Muscle testing is an art that is easily learned, however the science is in the details. Improper body and hand position, and the use of force and language can create false reading, which would lead to a misdiagnosis. 

Muscle grading is done using a point scale: a score of 5 means the patient is able to hold test position against resistance; a grade of 4 indicates the patient could not hold the test position; and a  grade 3 indicates no resistance except against gravity. Consistency of muscle testing is critical for both the stabilizing hand and the resistance hand. Hand placement, body position and force used must be maintained. 

The book, Muscles Testing and Function by Kendall, MccReary, Provance can provide additional information about muscle testing. Taking a beginners course on Applied Kinesiology may also be helpful. 

Patient supine test: gluteus medius, adductor, rectus femoris

1. Gluteus medius functions to abduct the leg and, when planted, stabilize the pelvis in single leg stance.
2. Adductor – long and short.  Testing the adductors is important because they act as a functional reaction muscle with the pelvic floor. 
3. Rectus femoris will go weak when the pelvis is not anchored.

Patient prone test: gluteus maximus and piriformis

1. Gluteus maximus is an important extensor and crosses the SI joint
2. Piriformis can overreact in any sacral dysfunction, leading to sciatic symptoms.  It crosses the SI joint and must be tested for pelvic instability.

Otorator internus is a lateral rotator the pelvic floor blends with. It is best tested in the sitting position.

After testing have the patient put on a SI belt, and re-test. In a diagnosis of pelvic instability, the patient will now test stronger. This would not be the case if the patient was simply presenting de-conditioned or with a nerve entrapment.

Program
1. Dispense the SI belt if instability is diagnosed.
2. Give home care exercise to strengthen the pelvic floor

• Get your patients to do breathing exercises. Teach abdominal breathing to start to activate the pelvic floor by increasing the intra-abdominal pressure (top left image).
• Get your patients moving. Start with a sumo squat, legs wide apart with internal external toe movement and progress to moving in all three planes with a 3D Lunge (top right, bottom left, bottom right images). 
• Give a balanced exercise to help stimulate the plantar muscles of the feet and activate the stabilizers of the spine.
•  Time the exercises with different levels of liquid.  Think of the bladder like a weight. As it fills the weight gets heavier.  Instruct your patients to drink a half liter prior to performing the 3-D lunge by a half hour, then increase over time to a litre.  This will help get the muscle to react to challenges of gravity and ground forces on the kinetic chain.

3. Adjust subluxation. Correction of subluxations is necessary to activate the pelvic floor through proprioception and improved joint functions. Coupled with stabilization exercises and the stability belt, this will heal and reverse pelvic floor weakness, thus eliminating the whispered disease. 

Dr. Scott Levine, DC, is the founder of MyRxX.com, a cloud-based video prescription exercise software. He runs the Vita Health Clinic located in downtown Toronto. His practice is focused on functional exams and treatments with background in applied kinesiology. Contact him at drscottlevine@vitahealthclinic.com.