Treatment of an Avid Cyclist with Urinary Dysfunction: Spinal Manipulative Therapy and High-Resistance Training - A Case Report
Cycling has always been a very popular sport and recreational activity for adults across the country. With the continual rise in cyclist-related injury, physical therapy services become crucial to maintain healthy riding habits. More cyclists are turning to physical therapy to avoid injury and continue to ride at high levels. One of the most common, however seldom reported, injuries for cyclists is urinary incontinence. Over the past several decades, physical therapists have utilized spinal manipulative therapy (SMT) to stimulate healing in a variety of musculoskeletal conditions,1 including urinary incontinence. In the following case report, a high-level cyclist was treated for urinary incontinence utilizing a series of SMT alongside high resistance strength training.
SPINAL MANIPULATIVE THERAPY: EFFECTIVENESS & MECHANISMS
Spinal Manipulation is an intervention utilized by Physical Therapists (PTs) to patients with various forms of musculoskeletal conditions. It is a localized high-velocity low-amplitude thrust to a joint segment in the body. Spinal Manipulation has been differentiated from mobilization techniques in that is occurs in a thrust technique through anatomically set barriers and does not occur in a lower velocity repetitive oscillation or sustained hold2.
After reviewing 52 articles specific to physical therapists performing spinal manipulation therapy, Kuczynski et al concluded that SMT is an effective and safe option for patients that suffer from low back pain or associated musculoskeletal conditions.3 However, the use of SMT on urinary incontinence without concomitant low back has rarely been studied. Nevertheless, Dangaria et al found that Sacroiliac Dysfunction is a common impairment that is associated with urinary incontinence symptoms.4
Sacroiliac joint (SIJ) dysfunction is pain that is associated with musculoskeletal symptoms secondary to an alteration in the normal joint motion at the articulation of the sacrum and ilium.5 This can result in groin pain, thigh tenderness, and even urinary incontinence. SIJ biomechanical insufficiencies have been found to be effectively corrected utilizing sacroiliac joint manipulation.2,6
HIGH-RESISTANCE STRENGTH TRAINING: EFFECTIVENESS & MECHANISMS
Urinary incontinence (UI) has been defined as involuntary leakage of urine through the urethra by the International Continence Society. It is a risk to health, social wellbeing, and personal hygiene. UI is commonly caused due to a lack of strength in the urethral sphincter muscles, pelvic floor muscles, connective tissue, and fascia.7,8
As UI has been shown to be caused by musculoskeletal deficiencies, high-resistance strength training can prove to be an effective means of treatment strategy. High-resistance training is a form of exercise where the individual undergoes short and intense bouts of strengthening followed by short intermittent rest breaks. This form has been shown to improve muscle strength through the musculoskeletal system.9,10,11
EVALUATION OF URINARY INCONTINENCE
Patient is a 34-year-old male who presented to outpatient physical therapy with complaints of pelvic floor dysfunction. Patient reported that in October of 2020 he went on a trip to Lake Placid. While on his vacation he was on his mountain bike. After a very bumpy ride he realized that he could not urinate the next day. He went to a Gastrointestinal (GI) specialist who at first prescribed Cipro Antibiotic (ABX), that did not help. He then visited a second GI specialist who diagnosed him with Urinary Incontinence (UI) and Pelvic Floor Dysfunction (PFD). Patient was then referred to physical therapy. Patient states that he is an avid cyclist who rides up to 700 miles per week. He wants to relieve his UI and return to cycling.
During the initial evaluation, patient reported significant pain in the region of the left Posterior Superior Iliac Spine (PSIS). Although he maintained full AROM of the lumbar spine, hip, and knee; rotational movement elicited 4/10 pain on the numeric pain rating scale (NPRS). Manual muscle testing revealed 5/5 strength in bilateral lower extremities, however an apparent 3/5 strength in the left adductor muscle group. He was tender to palpation over the region of the left SIJ with no obvious defect or ecchymosis. At initial evaluation, patient was positive for Gaenslen’s Test, Standing Forward Bend Test, and Thigh Thrust Test.12 Patient’s Oswestry Disability Index (ODI) at evaluation was a 17/50 34%.13
TREATMENT FOR URINARY INCONTINENCE AND SACROILIAC DYSFUNCTION
On the same day as the evaluation, the patient received a sacroiliac joint manipulation biasing the left SIJ. Patient was supine with the physical therapist standing on the right side of the body (to manipulate the left). Patient placed his hands behind his head and the PT moved the patient passively into side bending to end-range toward the left (targeted) side.2 PT then delivered a high-velocity low-amplitude thrust to the left Anterior Superior Iliac Spine (ASIS) in a posterior-inferior direction.
In addition, he performed 3 sets of 8 repetitions of resisted kettlebell squats. Afterward, he was instructed to perform hook-lying hip adduction isometrics and modified hip adduction planks.14,15,16
On his first follow-up 10 days post-initial evaluation, the patient reported to physical therapy with 2/10 pain and a subjectively reported ability to urinate without difficulty at night. Treatment was the same as the initial visit; however, rotational medicine ball slams, jump rope, and resisted core strengthening was added to his program.17,18,19,20
RESULTS
Patient was treated 8 times over a one-month span (2x per week for four weeks) with SMT at each session and progressively loaded resistance training. Immediately following the patient’s initial treatment with SMT at the SIJ, he was urinating relatively normal, pain-free, and a subjectively reported improvement in strength. His ODI improved to 5/50 10% at final treatment session. In addition, patient reported the ability to return to cycling up to 700 miles per week.
CONCLUSION
This case report suggests that the combination of Spinal Manipulation Therapy and high-resistance training may be a useful treatment strategy in patients with urinary incontinence and pelvic floor dysfunction. However, no cause-and-effect claim can be made as there is an absence of a comparison or control group. Also, current research is heavily dependent on females with urinary incontinence as opposed to males.21,22 A well-designed controlled trial is required to fully determine the additive potential of SMT and high-resistance training for this patient population.
AUTHOR
Jay Rosania, PT, DPT, OCS
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
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