Letter to the Editor
Conservative Management of Post-Surgical Urinary Incontinence Using Applied Kinesiology
Dear Sir,
I read with interest the article “Conservative Management of Post-Surgical Urinary Incontinence in an Adolescent Using Applied Kinesiology: A Case Report” which was recently published in your journal.1 This was the first case report in the literature regarding the occurrence of urinary incontinence in an adolescent female after appendectomy. There are a few reports published regarding chronic pain after appendectomy.2,3,4 This chronic pain had been attributed to nerve injuries secondary to appendectomy namely the ilioinguinal nerve, iliohypogastric nerve, lateral femoral nerve and the femoral nerve. The hip pain could be caused by injuries to one of these nerves or a few of them.
However, the urinary incontinence cannot be explained by nerve injuries incurred during appendectomy. The pelvic floor muscles as well as the sphincters which are involved in urinary continence are supplied by the pelvic and pudendal nerve, which does not lie close to the appendix. The course of the nerves also does not traverse the operative field of appendectomy.
We can only postulate that the pain from the injured nerves, caused spasm of the pelvic wall muscles, therefore interrupting the normal physiology of micturition. I am intrigued by the muscle inhibition theory as explained in the article as well as the chiropractic and applied kinesiology (AK) methods employed. The identification of the affected muscles via manual muscle test (MMT) and chiropractic manipulative therapy (CMT) has a sound basis and was proven to be effective in this patient and amazingly she was symptom free even after six years.
Since this is only a case report, a clinical trial would be needed to validate the success of this mode of treatment. Indeed, if proven, it would brighten the lives of our incontinent patients.
Yours sincerely,
Christopher C.K. Ho
Surgeon/Lecturer,
Urology Unit, Department of Surgery,
Universiti Kebangsaan Malaysia Medical Centre,
Kuala Lumpur, Malaysia.
E-mail:
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References
1. Cuthbert SC, Rosner AL. Conservative management of post-surgical urinary incontinence in an adolescent using applied kinesiology: a case report. Altern Med Rev 2011;16:164-171.
2. Wechselberger G, Schoeller T, Kiechl S, et al. Femoral nerve entrapment following appendectomy. Surgery 2000;127:115.
3. Kavanagh D, Connolly S, Fleming F, et al. Meralgia paraesthetica following open appendicectomy. Ir Med J 2005;98:183-185.
4. Stulz P, Pfeiffer KM. Peripheral nerve injuries resulting from common surgical procedures in the lower portion of the abdomen. Arch Surg 1982;117:324-327.
Author's Response to Dr. Ho
August 25, 2011
Dear Dr. Ho,
We thank you for your interest (particularly as a urologist) in the applied kinesiology, conservative management of urinary incontinence (UI) in our case report.
Cama reported on a case where right iliac fossa and abdominal pain remained after appendectomy and suggested this is not uncommon in patients who undergo appendectomies, and that it presents a diagnostic challenge.1 Our case also showed that right hip pain, abdominal muscle dysfunction, and numerous muscular impairments (muscles that crossed the pelvis, low back and proximal leg) were present after her appendectomy along with her urinary incontinence.
Critically important for all physicians who assess patients with muscle pain is the observation of Travell and Simons, that an active myofascial trigger point (MTrP) will inhibit the function of the muscle in which it is housed as well as those which lie in its target zone of referral.2 Carrying this thought forward, it has been suggested that, “Although weakness is generally characteristic of a muscle with active myofascial trigger points, the magnitude is variable from muscle to muscle, and from subject to subject. EMG studies indicate that, in muscles with active trigger points, the muscle starts out fatigued, then fatigues more rapidly, and finally becomes exhausted sooner than normal muscles.”3 Interestingly, these findings agree with those of Arnold Kegel, who first advocated pelvic floor muscle strengthening and retraining for stress incontinence. According to Kegel, pelvic floor muscles in women with urinary incontinence are inhibited and must be strengthened.4 Kegel’s observation is consistent with the research literature on the status of the pelvic floor muscles cited in our report.
In our case, we found that the AK method of MTrP diagnosis (the “muscle stretch reaction” and “pincer palpation”) were present in both the appendectomy scar (thereby producing referred pain and weakness in the underlying muscles) and in the gluteus maximus and right lateral abdominal oblique muscles as well. According to Simons et al., “The motor effects of MTrPs may be the most important influence they exert, because the motor dysfunction they produce may result in overload of other muscles and spread the MTrP problem from muscle to muscle.”2 This may mean that reflex-induced (and scar-tissue induced) inhibitions of the muscles of the pelvic floor may be common in patients with pelvic, lumbar, and symphysis pubis joint dysfunctions.5
In patients with articular dysfunction of the sacroiliac joint, muscle inhibitions are commonly found in the muscles that stabilize or attach to this joint, as either the cause or the effect.6 It is well documented that other muscles are dysfunctional and inter-related in patients with hip and low back pain – the multifidus,7 psoas,8 diaphragm,9 gluteals,10 pelvic floor muscles.11 The applied kinesiology manual muscle test identifies these functional disorders (inhibition) of the locomotor system. This is immediately followed by the applied kinesiology sensorimotor assessment (challenge and/or therapy localization, as described in our report), which corrects the sources of the inhibitions found. Biomechanical, biochemical, or psychosocial treatment is then given, and the muscle inhibition is corrected. This supports our suggestion that the AK method of diagnosis is aimed toward immediate, detectable causes. The MMT diagnosis of inhibited muscles and their covariance with patients’ musculoskeletal dysfunctions tells us something about the status of their condition as well as the responsiveness of their musculoskeletal disorder to treatment. The immediate and parallel improvement in muscle strength and patients’ dysfunctions after CMT that has been reported clinically supports this correlation as well.12
We agree with your suggestion that further research with defined inclusion criteria and validated outcome measures is needed if the effectiveness of AK procedures in managing UI is to achieve recognition and, if proven successful in clinical trials, become a cost-effective, non-invasive method for ameliorating this disturbing condition for our incontinent patients. Chiropractic treatment has been shown to be effective in other reports on bladder control problems.13-15
Scott C. Cuthbert, D.C. (corresponding author) *
Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC
* Chiropractic Health Center, P.C.
255 West Abriendo Avenue
Pueblo, CO 81004
(719) 544-1468
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References
1. Cama JK. Recurrent abdominal pain post appendectomy--a rare case. Pac Health Dialog 2010;16:78-81.
2. Simons D, Travell J, Simons L. Myofascial pain and dysfunction: The trigger point manual, Vol. 1: Upper half of the body, 2nd Ed. Baltimore, MD: Williams & Wilkins; 1999.
3. Mense S, Simons DG. Muscle Pain: Understanding Its Nature, Diagnosis, and Treatment. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.
4. Kegel AH. Progressive resistance exercise in the restoration of the perineal muscles. Am J Obstet Gynecol 1948;56:238-248.
5. Lee D. The Pelvic Girdle: An approach to the examination and treatment of the lumbopelvic-hip region. Edinburgh, UK: Churchill Livingstone; 2004.
6. Chaitow L, DeLany JW. Clinical Application of Neuromuscular Techniques: Volume 2, The Lower Body. London, UK: Elsevier; 2002.
7. Carpenter DM, Nelson BW. Low back strengthening for the prevention and treatment of low back pain. Med Sci Sports Exerc 1999;31:18-24.
8. Barker KL, Shamley DR, Jackson D. Changes in the cross sectional area of multifidus and psoas in patients with unilateral back pain. Spine 2004;29:E515-E519.
9. Hodges P, Kaigle Holm A, et al. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: in vivo porcine studies. Spine 2003;28:2594-2601.
10. Leinonen V, Kankaanpää M, Airaksinen O, Hänninen O. Back and hip extensor activities during trunk flexion/extension: effects of low back pain and rehabilitation. Arch Phys Med Rehabil 2000;81:32-37.
11. Pool-Goudzwaard AL, Slieker ten Hove MC, Vierhout ME, et al. Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:468-474.
12. International College of Applied Kinesiology. Collected Papers International College of Applied Kinesiology. Shawnee Mission, KS: ICAK USA; 2011-1976.
13. Leboeuf C, Brown P, Herman A, et al. Chiropractic care of children with nocturnal enuresis: a prospective outcome study. J Manipulative Physiol Ther 1991;14:110–115.
14. Blomerth PR. Functional nocturnal enuresis. J Manipulative Physiol Ther 1994;17:335–338.
15. Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. J Manipulative Physiol Ther 1994;17:596–600.
