Case report
Conservative chiropractic management of urinary incontinence using applied kinesiology: a retrospective case-series report

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Abstract

Objective

The purpose of this case series is to describe the chiropractic management of 21 patients with daily stress and occasional total urinary incontinence (UI).

Clinical Features

Twenty-one case files of patients 13 to 90 years of age with UI from a chiropractic clinic were reviewed. The patients had a 4-month to 49-year history of UI and associated muscle dysfunction and low back and/or pelvic pain. Eighteen wore an incontinence pad throughout the day and night at the time of their appointments because of unpredictable UI.

Intervention and Outcome

Patients were evaluated for muscle impairments in the lumbar spine, pelvis, and pelvic floor and low back and/or hip pain. Positive manual muscle test results of the pelvis, lumbar spine muscles, and pelvic floor muscles were the most common findings. Lumbosacral dysfunction was found in 13 of the cases with pain provocation tests (applied kinesiology sensorimotor challenge); in 8 cases, this sensorimotor challenge was absent. Chiropractic manipulative therapy and soft tissue treatment addressed the soft tissue and articular dysfunctions. Chiropractic manipulative therapy involved high-velocity, low-amplitude manipulation; Cox flexion distraction manipulation; and/or use of a percussion instrument for the treatment of myofascial trigger points. Urinary incontinence symptoms resolved in 10 patients, considerably improved in 7 cases, and slightly improved in 4 cases. Periodic follow-up examinations for the past 6 years, and no less than 2 years, indicate that for each participant in this case-series report, the improvements of UI remained stable.

Conclusion

The patients reported in this retrospective case series showed improvement in UI symptoms that persisted over time.

Introduction

Urinary incontinence (UI) occurs when there is leakage of urine involuntarily, most commonly in older patients.1 Fantl et al2 state that incontinence affects 4 of 10 women and 1 of 10 men during their lifetime, and about 17% of children younger than 15 years. A large postpartum study of the prevalence of UI found that 45% of women experienced UI at 7 years postpartum. Thirty-one percent who were initially continent in the postpartum period became incontinent in the future.3

Continence depends primarily on the adequate function of 2 muscular systems—the urethral muscular support system and the sphincteric muscular network of the pelvic floor muscles (PFM).4 These systems include the levator ani muscle, detrusor muscle, and pelvic floor muscles (coccygeus, obturator externus, obturator internus, gemellus inferior, gemellus superior, and levator ani), as well as the pudendal nerve that emerges from the sacral plexus. The striated muscles of the pelvic floor play an integral role in the closure of the lumen of the urethra and the maintenance of continence.5 In women with stress UI, ineffective contraction or control of the pelvic floor muscles permits descent of the bladder neck with inadequate closure of the urethra, resulting in the leakage of urine.6

The comorbidities of lumbopelvic pain, incontinence, and breathing pattern disorders are slowly being elucidated.7, 8 Musculoskeletal impairments, and specifically muscular imbalances between agonist and antagonist muscles in the pelvis, create articular strain and soft tissue stresses that can lead to pain and UI.9

Current observations suggest that patients with stress incontinence may have imbalances in several lumbopelvic muscles that inhibit the PFM and lead to incontinence.10 Recent data also indicate that breathing difficulties and incontinence are associated with increased chances for the development of low back pain,11 demonstrating that the interactions between the lumbar and pelvic muscles and joints may be an important consideration in cases of UI.

A recent study assessed strength changes in the PFM using a perineometer (a pressure electromyograph that registers contractions of the PFM) after the application of chiropractic manipulative therapy (CMT). This investigation showed that phasic perineal contraction and basal perineal tonus, force, and pressure increased after CMT.12 The duration of these force changes will have to be assessed in subsequent studies of this type.

It was Arnold Kegel13 who first advocated pelvic floor muscle strengthening and retraining for stress incontinence, indicating his recognition of the importance of muscle inhibitions in cases of UI. Kegel's program of strengthening the inhibited muscles of the pelvic floor has shown some promise.14, 15, 16, 17 The potential usefulness of the applied kinesiology manual muscle test (AK MMT) approach in this model would be the identification of the inhibited muscles involved and the therapeutic approaches used to immediately address these inhibitions with CMT. A number of other reports have been made on the use of CMT for elderly patients with UI.18 Stude et al19 reported a case study of a 14-year-old female adolescent treated with CMT who recovered completely from traumatically induced UI. The applied kinesiology (AK) approach to a postappendectomy-induced case of UI has been described as well.20 Chiropractic manipulative therapy has been shown to be effective in other reports on bladder control problems.21, 22, 23

Lumbar and sacral nerve root compression as the result of lumbar and sacral articular dysfunction and degeneration has been identified as a potential cause of pelvic pain and organic dysfunction, a term coined by Browning.24, 25 It is hypothesized that there may be a relationship between lumbar and pelvic muscles and UI.

The purpose of this case series is to report on the findings of chiropractic management of patients with UI. The patients included in this report presented for chiropractic treatment of either UI directly or another condition, with their UI being disclosed during the initial history taking at the beginning of treatment. Each patient signed informed, written consent forms to be examined and treated and to be included in this case-series report.

Section snippets

Assessment procedures

The testing of the voluntary skeletal muscles is based upon the procedures and principles of Kendall and Kendall, who described that a given muscle, when tested from a contracted position against increasing applied pressure from the examiner, could either maintain its position and be rated as “facilitated” or “strong,” or break away and thus be graded as “inhibited” or “weak.”26 A recent review found the reliability of manual muscle testing (MMT) to be “good.”27 Clinical guidelines for the

Discussion

This review of 21 cases of UI has suggested that there may be a relationship between MMT of the pelvic and lumbar spinal muscles (particularly the PFM), as this seemed to be consistent in each of the selected cases.

The following is a discussion of some of the theories that may explain this relationship. The PFM run from the pubic symphysis to the ischial spines bilaterally. These muscles and fascia continue superiorly, with the myofascia surrounding the pelvic organs and ligaments of the pelvic

Conclusion

This report discussed a chiropractic treatment approach and the resolution, considerable improvement, or slight improvement of UI in 21 cases. Further research with defined inclusion criteria and validated outcome measures is needed to evaluate the effectiveness of CMT and AK procedures in managing UI.

Funding sources and potential conflicts of interest

Dr Cuthbert is on the Board of Directors of the International College of Applied Kinesiology. Dr Rosner receives a consulting fee and support for travel to meetings and is the Research Director of the International College of Applied Kinesiology–USA.

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