Week 7 Case Pelvic floor Physiotherapy

According to HOAC II

Phase 1: referral, registration and initial hypothesis

Mister Frank, 48 years old
Chronic low back pain and lower urinary tract symptoms (LUTS)

Initial hypothesis
H1 Frank has lower back pain due to a motor control impairment in the lower back.
H2 Frank has lower urinary tract symptoms due to motor control impairment of the pelvic floor muscles.
H3 Frank has lower back pain due to a lower crossed syndrome
H4 Frank has chronic lower back pain due to an SI dysfunction caused by possible trauma
H5 Frank has chronic lower back pain due to a psychosocial factor like stress and anxiety in his life.
H6 Frank has chronic lower back pain due to a herniated disc

Screening for red flags

- General red flags

- Region specific red flags

Phase 2a: history and revised hypothesis

Complaints: recurrent chronic low back pain, nagging pain, for 5 years
Provocation: get up after long sitting, get out of the car after long driving, standing for long periods
(static load).
Reduction: walk & move

2 physiotherapists: 1st massage, 2nd global muscle training. Both short-term effects.
• Work: catering. Standing work, 40 hours. Irregular and physical heavy work. Receives
sickness benefit of 25% for 4 months.
• Sport: not
• Hobby: touring by car
• Private: married, 2 adolescents living at home
• Personal: perfectionist, control freak
• Environmental: takes care of his mother. Cannot be understood by his boss.
• Medicines: -
• Medical History: -
 • Limitation in activities:
o Getting out of the car after a long period of sitting >60 min.
o Long period of standing >30 min
• Limitation in participation:
o Work in catering now for 75% of normal working hours.
o Can take up to 1 hour in the car. (Long tours are his hobby)
Additional questions:
Urology:
• Voiding frequency:
• Daily:10x, Night:2x. Fluid intake 1,5L
• Micturition:
• hesitation, weak interrupted flow. Always strain to urinate, after dribble in
underwear. Bladder feels empty, but soon urgency. Cannot hold pee for a long time.
• Incontinence: not
• Assessment urologist: no pathology and normal volume prostate
Bowel and stools sexology:
• Defecation: normal stool rate.
• Bristol Stool Scale: 3-4.
• No problems
Sexology:
• Sexually active, no complaints
• No negative experiences or abuse

PIP’s:
- Has chronic lower back pain, nagging pain, for 5 years
- Pain provocation after getting up after long sitting (getting out of car after long drive) >60min
- Pain provocation and limitation of activities after standing for long periods (static load) >
30min
- Limitation in participation – works only 75% of working hours; can’t drive more than 1h
- Micturition: hesitation, weak interrupted flow. Always strain to urinate, after dribble in
underwear. Bladder feels empty, but soon urgency. Cannot hold pee for a long time.

NPIP’s
- personal an environmental factor  he has psychosocial factors like stress and anxiety that
could have a negative effect on the recovery time.

Adjusted hypotheses
H1 Frank has lower back pain due to a motor control impairment in the lower back in relation with lack
of core stability. – ADJUST: pain after sitting and standing for a long time
H2 Frank has lower urinary tract symptoms due to motor control impairment of the pelvic floor
muscles. – ACCEPT: has some symptoms of pelvic floor muscles weakness; weak interrupted flow
while urinating; cannot hold pee for a long time
H3 Frank has lower back pain due to a lower crossed syndrome caused by a sedentary lifestyle and lack
of physical activity. – ADJUST: sits in car for a long period of time; doesn’t do any sports
H4 Frank has chronic lower back pain due to an SI dysfunction. – PERSIST
H5 Frank has chronic lower back pain due to stress caused by his stressful environment. (he is a
perfectionist, needs to take care of his mother, boss cannot understand him). – ADJUST
H6 Frank has chronic lower back pain due to a herniated disc – REJECT: no complaints of radiating pain
in the legs
Phase 2b: assessment on ICF level
NPIP’s
Testing the hypotheses following this scheme:

Hypothesis à Goal à Intervention à Outcome à Evidence

Assessment
H1 Frank has lower back pain due to a motor control impairment in the lower back in relation
with lack of core stability.
Objective Determine if there is an MCI in the lower back
Tool Luomajoki movement control protocol
- Waiter’s bow
- Pelvic tilt
- Sitting knee extension
- One leg stance
- Prone knee bend
- Forward and backward rocking
Outcome Positive  there is a motor control impairment in his lower back
EBP Luomajoki 2007
Luomajoki, H., Kool, J., de Bruin, E. D., & Airaksinen, O. (2007). Reliability of movement
control tests in the lumbar spine. BMC Musculoskeletal Disorders, 8(1), 1.
https://doi.org/10.1186/1471-2474-8-90
H2 Frank has lower urinary tract symptoms due to motor control impairment of the pelvic floor
muscles
Objective Determine if there is a pelvic floor MCI
Tool As a general physiotherapist, you cannot test the MCI of the pelvic floor  refer to a pelvic
floor specialist
Outcome Positive  there is a motor control impairment of the pelvic floor
EBP Practice based evidence
Referral?
H3 Frank has lower back pain due to a lower crossed syndrome caused by a sedentary lifestyle
and lack of physical activity.
Objective Determine if he has a lower crossed syndrome (LCS)
Tool Length test
- Iliopsoas (Thomas test)
- Erector spinae
-
Strength test
- Gluteus maximus
- Transvers abdominus
Outcome Length test
- Iliopsoas and erector spinae are shortened on both sides.
Strength test
- Gluteus maximus and transverse abdominus are weak on both sides.
EBP LCS?
Dutton’s?
H4 Frank has chronic lower back pain due to an SI dysfunction.
Objective Determine if there is an SI dysfunction
Tool Cluster of Laslett
- Distraction test
- Thigh thrust
- Compression test
 - Sacral thrust
Outcome 0/4 are positive  there is no SI dysfunction
EBP Sensitivity: 88%  rule out SI dysfunction
Specificity: 78%
Laslett 2005
H5 Frank has chronic lower back pain due to stress and low quality of life caused by his
environment. (he is a perfectionist, needs to take care of his mother, boss cannot understand
him).
Objective Determine if he is stressed and how his quality of life is
Tool DASS 21
WHOQOL-BREF questionnaire
Outcome DASS 21  positive; moderate stress
WHOQOL-BREF  positive
EBP Skevington SM, Lotfy M, O'Connel KA, WHOQOL Group. (2004). The World Health
Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results
of the international field trial. A report from the WHOQOL group. Quality of Life Research,
13(2), 299-310.
DASS 21 evidence

Summary of the assessment results

Phase 3: final hypotheses, advice and treatment targets

Final hypotheses
H1 Frank has lower back pain due to a motor control impairment in the lower back in relation with lack
of core stability.
H2 Frank has lower urinary tract symptoms due to motor control impairment of the pelvic floor
muscles.
H3 Frank has lower back pain due to a lower crossed syndrome caused by a sedentary lifestyle and lack
of physical activity.
H4 Frank has chronic lower back pain due to an SI dysfunction. – REJECT
H5 Frank has chronic lower back pain due to stress caused by his stressful environment. (he is a
perfectionist, needs to take care of his mother, boss cannot understand him).
 ACCEPT all hypotheses except the SI dysfunction

Explanation
Frank is a 48-year-old man that complains about chronic lower back pain has urinary tract symptoms
(LUTS).

After several tests, we can conclude that he has MCI in his lower back, which means that he has poor
control over his local stabilizers of the lower back. The lower back pain and LUTS is caused by the
motor control impairment of his pelvic floor, which can only be teste by a specialist. Due to his
inactivity and sedentary lifestyle he developed a lower crossed syndrome (LCS). Moreover, his
psychosocial and environmental factors cause him to be stressed and have a poor quality of life.

Link between LBP and MCI of pelvic floor  what causes what?

Explain the adopted hypotheses. Evidence based!

Prognosis

What is the prognosis? Can you answer the question for help? Evidence based! (clinimetrics)
Recovery obstructive factors
Non-compliance of rehabilitation protocol

Etc.

Which factors will influence the recoveryl? Evidence based! (clinimetrics)

Treatment plan
End goal (SMART)
Frank wants to be able to drive to work and work with decreased back pain (NPRS<2) and work
without complaints (PCS>8) within 12 weeks. He wants to have a good flow while urinating and
bladder control within 6 months.

Sub goals (SMART)

1. Frank has an improved motor control impairment in the lower back (0/6 test positive of the
Luomajoki movement control protocol) within 6 weeks.
2. Frank regains full length of the iliopsoas and erector spinae and regain full strength (MRC 5)
of the gluteus and abdominal muscles within 6 weeks.
3. Frank decreases his stress levels to mild stress on the DASS 21 questionnaire within 8 weeks.
4. Frank increases his activity level to 100 minutes of weekly physical activity within 6-8 weeks.

The Papendal protocol is a core stability test used to determine the core stability of patients and is
used in rehabilitation. I chose not use this protocol in this case, because it is meant for athletes and
due to the fact that my patient is not physically active, this test would be too hard for him to perform
properly.

Goal Tool Protocol

Frank has an improved
motor control impairment in
the lower back (0/6 test
positive of the Luomajoki
movement control protocol)
within 6 weeks.
Strengthening of local Local stabilizer muscle strengthening
stabilizer muscles of Neutral
lower back Supine:
 patient tries to contact the deep core
muscles. Try to keep muscles
contracted for 10 seconds. Patient
needs to be able to breathe and talk
while contracting. Practice this 3x 10s
Once capable of holding the contraction
for 10 seconds, increase the time.
Always repeat 3x 10/20/30s and repeat
3x a week.

On hands and knees:

 find neutral position of the spine and
try to contract the deep core muscles.
Same protocol as in supine position.

Sitting:
 find neutral position of the spine and
contract the deep core muscles. Same
protocol as in other position.

Continue with control through

direction:
 Supine:
 bring up knee and hip into 90°
flexion; contract the deep core and back
muscles; extend the hip until you feel
you back coming of the floor. Repeat
with every leg 3x12 – 3x a week
 bring knees to 90°; perform chest
press with dumbbells. Repeat 3x12;
keep local muscles contracted!
repeat the 12 repetitions only if the
quality of the movement is correct!

On hands and knees:

 contract deep core and back
muscles; forward and backward rocking
(like in Luomajoki assessment); keep
spine in neutral position

Standing
 standing with the back against the
wall; contract the deep core and back
muscles; keep lower back against the
wall while flexing the hip and knee to
90°. Repeat each leg 3x12 – 3x a week

Strengthening of pelvic Pelvic muscle strength

floor muscles In all the exercises above, instruct the
patient to hold and contract the deep
core muscles and to also try to contract
the muscles that keep him from
urinating. Afterwards ask the patient to
contract the muscles that keep him
from passing wind. After that, ask the
patient to squeeze both muscles at the
same time and hold the contraction.
Hold these contractions as long as
possible, while still being able to
breathe and talk. Increase the time
gradually.

EBP: Javadian, Y., Behtash, H., Akbari, M., Taghipour-Darzi, M., & Zekavat, H. (2012). The effects of
stabilizing exercises on pain and disability of patients with lumbar segmental instability. Journal of
back and musculoskeletal rehabilitation, 25(3), 149–155. https://doi.org/10.3233/BMR-2012-0321

Frank regains full length of Dynamic/static Iliopsoas stretches

the iliopsoas and erector stretching - 4x 30s – 3x a week
spinae and regain full
strength (MRC 5) of the
gluteus and abdominal
muscles within 6 weeks.

Errector spinae stretches

- 4x 30s – 3x a week

Strength training
Gluteal muscle strength exercises
- Forward step-up
o 3x12 each leg – 3x a
week
o Every week increase the
height to make exercise
harder

- Bridge/ Hip thrusts

o 3x12 – 3x a week
o Start with bridge and
continue with hip
thrusts after 2 weeks
 Abdominal muscles exercises
-  see subgoal 1: local stabilizer
muscle strengthening
- Once stability in deep muscles
achieved  sit-ups; 3x 12 – 3x a
week

EBP: Konrad, A., Stafilidis, S., & Tilp, M. (2017). Effects of acute static, ballistic, and PNF stretching
exercise on the muscle and tendon tissue properties. Scandinavian journal of medicine & science in
sports, 27(10), 1070–1080. https://doi.org/10.1111/sms.12725

Reiman, M. P., Bolgla, L. A., & Loudon, J. K. (2012). A literature review of studies evaluating gluteus
maximus and gluteus medius activation during rehabilitation exercises. Physiotherapy theory and
practice, 28(4), 257–268. https://doi.org/10.3109/09593985.2011.604981

Frank decreases his stress
levels to mild stress on the
DASS 21 questionnaire
within 8 weeks.
Education Educate the patient about his
psychosocial factors (perfectionist,
needs to take care of mother, boss
cannot understand him) and explain
how these factors can influence his
recovery if not taken care of.

Breathing exercises Breathing exercises

 365 method (5s in / 5s out); repeat
10 times every day
 4-7-8 method (breath in for 4s / hold
for 7s / breath out for 8s); repeat 10
times, every day

Mindfulness Mindfulness
(Meditation/Yoga)  in the first session explain to the
patient what mindfulness is and how it
can benefit him. Advise patient to use a
mediation app on his phone and to try
to meditate every day for 10-15
minutes. Advise the patient to
participate in a yoga class (1x a week for
1h)

EBP: Daphne M. Davis, PhD, and Jeffrey A. Hayes. "What Are the Benefits of Mindfulness? A
Practice Review of Psychotherapy-Related Research,". APA journal Psychotherapy (Vol. 48, No. 2)

Paterick, T. E., Patel, N., Tajik, A. J., & Chandrasekaran, K. (2017). Improving health outcomes
through patient education and partnerships with patients. Proceedings (Baylor University. Medical
Center), 30(1), 112–113. https://doi.org/10.1080/08998280.2017.11929552

Frank increases his activity
level to 100 minutes of
weekly physical activity
within 6-8 weeks.
Education Educate the patient about the necessity
of physical activity and the connection
of lack of physical activity and the lower
back pain and MCI. Advise patient to
choose an activity (running, swimming,
 playing soccer, etc) and educate about
the following:

WHO – physical activity Adults aged 18–64

and adults - 150 minutes of moderate-
intensity aerobic physical
activity throughout the week or
do at least 75 minutes of
vigorous-intensity aerobic
physical activity throughout the
week
- Aerobic activity should be
performed in bouts of at least
10 minutes duration.
- Muscle-strengthening activities
should be done involving major
muscle groups on 2 or more
days a week.

EBP: World Health Organization

Steffens, D., Maher, C. G., Pereira, L. S., Stevens, M. L., Oliveira, V. C., Chapple, M., Teixeira-
Salmela, L. F., & Hancock, M. J. (2016). Prevention of Low Back Pain: A Systematic Review and
Meta-analysis. JAMA internal medicine, 176(2), 199–208.
https://doi.org/10.1001/jamainternmed.2015.7431

Reflection: