Manual Therapy Forum

Welcome to our first guest post on the Forum!  Below, you will read about a recent complex case that our previous podcast guest, Diane Lee, managed with some sound clinical reasoning.  She utilized her approach of the Integrated Systems Model and talks about how that was used for this patient.  If you’d like to listen to the podcast episode we did with Diane, you can find that here.  Leave Diane and myself a comment below and let us know what you think (you can also do that on our social media accounts as well)!

As a MSK physical therapist, how do you assess and know when to treat the pelvic floor? Or do you?

Let me start with a short case report. This will highlight why I feel that every clinician must have tools to assess every muscle and know how to determine if it is playing a role, and if so, what role?  This includes the muscles of the pelvic floor.  Yes, there are clinicians specially trained to assess and treat the pelvic floor and they are often guilty of not assessing and knowing how to treat the foot or the cranium, both of which can play a huge role in the behaviour of the pelvic floor.  So, the story first, then some anatomy and common relationships I see in the clinic. If you want we can talk about the evidence, there is a lot, but let’s stay clinical for now.

In January, a long-time client who lives 1 hour from my clinic developed insidious onset pain over her right medial knee when walking. Rest did not reduce her pain, so she sought local care and unfortunately got local treatment to her knee. ‘Some kind of rubbing’ were her words. The treatment didn’t work so she saw someone else. The second therapist noticed that her hips were really ‘stiff’ and confidently told her with minimal examination that he could ‘fix her in no time and you will be snowshoeing by the weekend’. One session of dry needling to her gluts, tensor fascia lata and adductors of both hips was given and the result was that she couldn’t walk the next day or for 10 days thereafter.  He didn’t respond to her email when she contacted him to say she wasn’t snow shoeing, let alone walking. She didn’t go back, found him ‘cocky’ which I later found were an interesting choice of words.

She decided to drive the hour for a whole body/whole person Integrated Systems Model assessment. Understanding the relationship between, and within, body regions and systems (neural, articular, myofascial, visceral etc.) and the consequences of impaired function of one region/system on another is complex. Many health practitioners specialize in body regions, and/or systems and treatment is often based on the practitioner’s training and experience. However, this reductionistic approach may not be optimal in that each body region is not only an integrated system within itself (i.e. comprised of many differentiated yet linked parts (Siegel 2010)) but is also integrated, and interdependent, as part of the whole body/person.  No studies have correlated persistent pain anywhere in the body to a consistent impairment (Clauw 2015). Therefore, in persistent pain conditions such as low back pain, metatarsalgia, TMD, headache etc., understanding what body region and system should be treated requires an individual clinical reasoning approach. This is true whether the pain mechanism is primarily nociceptive, nociplastic, or neuropathic. The Integrated Systems Model (ISM – Lee & Lee 2011, Lee 2015) is an evidence-informed, clinical reasoning approach that embraces, and enhances, the concepts of the regional interdependence model (Sueki et al 2013).  

Back to the story. I asked her more questions. What has changed in your exercise/activity program? “Nothing” she says. I reply “And nothing has happened to you, i.e. no trauma”? No. She had no idea why her knee and now both her lower extremities, pelvis and groins were aching and her hips were so ‘stiff’. She had X-rays taken and was told they were normal.

ISM begins by choosing a task that has meaning. For her, walking was a meaningful task. To be able to walk efficiently, one has to be able to stand on one leg and step forward with the other. So the examination began with a standing positional screen and the step forward task (left and right leg was the screening task evaluated).  Analysis of the whole body in this task for optimal alignment biomechanics and control was done.

Findings:

Both of her hips were not centered in the acetabulum in standing and failed to center in either the left or right step forward task.

The left and right SIJs were well controlled in both standing and the left and right step forward task.

There multiple thoracic rings translated/rotated, which suggested her thorax was compressed; however, no correction of any of them improved the alignment of her hips in standing nor the biomechanics required for a step forward task. 

In an ISM assessment, further assessment (active and passive mobility, active and passive control) is done on what is called the driver. The body region where the greatest number of impairments are improved when the alignment, biomechanics and/or control of the driver is corrected.  For this patient, the only correction that improved her standing and step forward task was a hip centering correction. So the hips were considered the driver and body region for further assessment.

Both hips were incredibly limited in active and passive flexion and rotation (both internal and external) and the end feel on passive testing was neuromuscular, not articular. When the left or right femoral head was passively centered in the acetabulum and then slowly released, the vectors (usually muscles here) that are compressing the hip can be determined and prioritized (see the video accompanying this post). This test is adapted from the Barral concept of ‘load and listen’ for those of you familiar with Barral’s work and methods. On release of the passive hip correction (this is done in supine), the first vector of pull was strong and medial, more medial than the adductors and lower than the lowest transverse abdominals (transversus abdominis and internal oblique). The next test is to palpate the muscle whose anatomy fits with the location of the pull – this would be iliococcygeus here.

External palpation of iliococcygeus on the left and right revealed a very tender over-active muscle. Now the impact of the dry needling session made sense. The reactors to the problem (gluts, TFL, adductors) were treated, not the cause.

So I asked “Have you been experiencing any change in your continence or pelvic floor since I’ve seen you last”? “No” she says, “because all my friends are becoming incontinent (she is over 60) so to prevent this and having to wear Depends like they all do I have been doing tons of Kegels every morning for 15 minutes”.

“When did you start this routine”? “Last fall”. Remember that her knee pain started in January. “Have you been relaxing your pelvic floor muscles as well or just contracting them”. “Why”? she asks. “I thought you were supposed to contract your muscles down there and hold your belly in always”. No wonder her hips are so compressed!  The pelvic floor myofascial sling is continuous from one greater trochanter to the other.  Take a look at the MRI below. Iliococcygeus originiates from the fascia of the obturator internus thus forming a complete sling of muscle/fascia from hip to hip.  Over recruit your pelvic floor and your ‘hips suck in’. You can try this on yourself in standing.  Relax your pelvic floor muscles while palpating your left and right greater trochanter, then contract your pelvic floor.  You should feel the greater trochanters approximate towards the midline. Can you imagine what this would feel like if you kept this contraction on all the time.  Try this, squat with your butt way back and the move your hips into medial and lateral rotation.  Stand back up. Contract your pelvic floor, keep the contraction the squat and repeat the hip movement. Much less, right?  This was my patient. 

She just needed Shirley Sahrmann’s advice – Stop doing that!! But in a professional way.

So, I provided her with some education on how to get her pelvic floor to relax (co-ordinated with her breathing of course) and her hip mobility was 75% restored both passively and in the squat task I had you just do.  Her femoral heads centered in standing and in the step forward task but ONLY when she focused on keep her pelvic floor relaxed, her groin pain disappeared immediately and she is a bit blown away that she has caused this by trying to help herself. Habits matter, strategies matter and looking at the whole person and getting the whole story is critical.

Now she has to undo the habit. If she is diligent, I don’t think it will take more than 30 days now that she understands how the pelvic floor muscles work and why just doing Kegels for the hell of it is not such a great idea if you don’t also practice letting go.

This is not new information but the message is not reaching the public nor is the importance of having some tools in your tool box as a MSK clinician to assess and treat the pelvic floor. Two excellent PTs missed this because they didn’t know how to assess the pelvic floor and its relationship to the hip (let alone the foot, thorax, cranium etc.). Nothing exists in isolation, everything is connected and in relationship.  I’m sure they see lots of people with pelvic girdle pain, hip and knee pain, foot pain and even headaches and are missing an essential component of the picture by not:

1. Asking about symptoms or issues pertaining to the pelvic floor
2. Explaining the relationship between the pelvic floor and the coccyx and thus the dura and many things cranial
3. Having tools (manual or ultrasound) to assess the function of the pelvic floor muscles and if impairment is noted whether the impairment is related to what they have come to see you for. The pelvic floor is, after all, part of the thoracolumbopelvic-hip ‘core’ system so how can you assess the core if you have no idea how to assess its bottom?
4. Having treatment options for the pelvic floor impairment
5. Knowing when to refer to a pelvic floor specialist.

So, where to start?  If you don’t work with ultrasound imaging and you have trained manual therapy hands, it’s not hard.

1. Learn the anatomy of the pelvic floor muscles
2. Find a willing partner to let you palpate the muscles on – preferably a trained pelvic floor PT but if not work it out
3. Test the 3 R’s of muscle testing – activation at rest (tender to palpation?), can they recruit, can they relax.

Next – let’s talk about pressure systems and why the pelvic floor is more often a reactor to other impairments – that wasn’t my patient’s story here, her pelvic floor was the actor, not the reactor and the listening on passive correction and release of the hip was the key test that revealed this.

If you would like to learn more about the Integrated Systems Model, please visit www.learnwithdianelee.com