Connection of Ribcage tightness, stress, and grade 3 prolapse in 28 months postpartum

INTRODUCTION

A 34-year-old woman presented at 28 months postpartum (the baby was born in August 2019) with a feeling of pressure in the vagina, something is falling out. The client also presented with stress urinary incontinence, upper back tightness, and her ribs were feeling stuck. The client was seeing a chiropractor. The client has h/o two natural births with min tearing. The client is separated from the first daughter’s father; the Client stated her second daughter’s father passed away when she was pregnant. The client stated she is in a lot of stress. The client is currently breastfeeding, and her menstrual cycle returned on 12/20.

CLIENT CHARACTERISTICS

The client stated she had h/o falling on the coccyx when she was in her teens. The client has h/o asthma, hypothyroid, and constipation. The client has h/o both ankle sprain in the past, and her ankles rolled. The client is under a lot of stress from her personal situation. The client reported she also has a tendency to clench her jaws. The client stated she has feeling fullness in the vagina, and something is falling out since she started having intercourse with her recent partner. The client also presented with clo upper back tightness and right hip pain, mainly with walking and carrying her child. The client reported her pubic symphysis bone feels like it moves while rolling over, and it hurts since her pregnancy. The client stated she wanted to get help earlier, but with the pandemic, she could not get help. The client’s chiropractor referred her for pelvic floor physical therapy. 

EXAMINATION FINDING

• Posture: Forward Head, Rounded Shoulders increased arch at the thoracolumbar region, left pelvis elevated and upslip, ribs rotated left, left shoulder depressed Wide ribcage angle present-100
• Breathing mechanics: decreased lateral rib expansion (mobility), and posterior expansion affecting the coordination between the diaphragm and pelvic floor, affecting pressure management.
• External observation of pelvic floor: decreased lift, urogenital prolapse grade 3 present
• Internal pelvic floor assessment: Vaginal: weakness of pelvic floor present with the strength of 3-15
• Muscle strength of hip muscles
• Rhip abd: 3/5, extension: 3/5, add: 3/s, flexion: 3-15 L hip abd: 3/5, extension: 3/5, add: 3/5, flexion: 3-15
• Both knee flex: 3+/5, extensor: 3+15 
• Both ankle DF: 4s, evertor: 3+/5 (h/o ankle instability present), inverter: 4
• Upper abdominal clenching present and not able to engage lower Tranversus abdominis. The pelvis is in excessive anterior tilt in standing/weight bearing.

ROM:

• Lumbar spine flex: Hands reach to the floor, extension: major loss, coccyx mobility is also limited in extension
• Hip ROM R hip flexion: 0-85, L: 0-90
• ER: 0-40, L: 0-50 Tightness of both hips present (R>L).
• Thoracic spine extension: major loss, rotation to R/L: mod loss
• U/L stance test: The patient presented with poor load transfer while standing on one leg. U/L stance on right: 2-3 sec hold without assist with poor proximal stability. L: 5 sh without assist R SI joint gapping present with U/L
• Palpation: Both psoas tightness present (R>L), decreased bladder fascial mobility, tightness of fascia over ribcage present, parasternal fascia tightness present, and decreased diaphragm mobility. Obturator tightness present (R>L) and tenderness present internally on obturator internus muscle/levator ani on the right. Upper abdominal fascial restrictions present. Gluteus fascia tightness present (R>L). Left hip adductor fascia tightness/tenderness present. Tightness of masseter muscle, SCM/scalene present. Tightness of right sacrospinous ligament present.

Based on the assessment, the treatment was focused on

1) Myofascial release/visceral mobilization and muscle energy technique

2) Rib cage/thoracic spine mobility

3) Hip joint/Sacroiliac joint mobility on both sides to improve symmetry

4) Breathing mechanics and stress management

5) Strengthening of hip/core/pelvic floor/diaphragm

6) proprioception/balance exercise

TREATMENT

The client’s goals were: 

1) Improve upper back/rib mobility in able to breathe better

2) Improve mobility/strength in the hip/thoracic spine/lumbar spine in able to walk/run without % pain and feeling of falling out

3) Improve strength/coordination of diaphragm and pelvic floor to be able to lift/move furniture without % pain/feeling of falling out

The client was seen 1x/week for 6 weeks initially with a focus on: 

1) Pelvic alignment- muscle energy technique to correct pubic symphysis alignment and stabilize the pelvis

2) Myofascial release of upper abdomen, ribcage fascia, parasternal fascia/left hip adductors/gluteal fascia/fascia around the sacrum/sacrospinous ligament on right, masseter, scalene/SCM. Internal pelvic floor muscle release was performed only 2 times with focus on bladder fascia release with obturator muscle/levator ani release on right side with breathing.

3) Visceral and fascia release around the bladder, uracher ligament/obturator fascia along with hip mobility, rib mobilization with breathing

4) Breathing mechanics using the foam roller (MELT rebalance which helps a lot with lateral and posterior expansion), and in child’s pose which also help to improve posterior and lateral expansion

5) Mobility exercises – cat cow, cobra-spine extension, side lying thoracic rotation, hip mobility – flexion/abd/ER. Foam rolling of gluteus fascia, upper back for HEP

6) Strengthening exercises with focus on hip adductors- that helps a lot to lift pelvic floor, lower transversus abdominis, gluteus medius-side lying hip abd/clam shell/reverse clam, hip flexors, hamstring During the course of the first 6 weeks, the client improved with pelvic alignment, rib mobility/thoracic spine/hip mobility, hip and core strength. Client declined any feeling of falling out or stress incontinence with her functional activities. Client still struggled with right hip pain, tightness in hips (R>L), upper back tightness with stress/feeling stuck in rib mobility when under stress, lower TA weakness.

The client was seen 1x week for the next 12 weeks: 

1) Continued fascial release.

2) Diaphragm strengthening with balloon breathing in side lying, child’s pose, partial to deep squats

3) Continued strengthening – side lying upper extremity ER, hor abd/ press out with theraband, prone rows/extension/flexion of both shoulders, half kneeling PNF chop, bird dog, slider lunge, heel raises 4) Balance exercise- U/L stance on level surface-airex stabilizer, BOSU lunges, cone step overs

During these 12 weeks, major changes happened. The client was able to release her emotions during fascial release and with balloon breathing. The stressors were there but she was able to manage them a lot better. The client started feeling less stiff, right hip pain went away, and improved with strength/balance/stability. The client stated her ankles feel a lot more stable. The client started getting less stiff after stress/travel. We never discussed her past, she sometimes used to express her feelings and current stress. The client still felt some struggle with balance on the right LE; running mechanics was off- hard landing while running, breath holding, feeling of lower abdominal sag, decreased shoulder movement- decreased upper trunk rotation (L>R).

Next 1x/ week for 6 weeks 

1) Cont work on breathing with balloon with half kneeling PNF chop, slider lunges, side plank with clamshell, quadruped bridge, bird dog

2) Foam rolling thoracic spine/rib cage

3) Balance/proprioception- U/L heel raises, dynamic balance exercises

4) TRX and BOSU plank with hip flexion for lower TA engagement, BOSU scapular stability exercises.

5) Running mechanics: The client progressed to running without any % pain/leak/feeling of falling out, improved breathing mechanics, strength/stability. The client felt improved breathing mechanics, no feeling of lower abdominal sag, and declined any upper back tightness. Client improved upper back and shoulder mobility with running.

SUMMARY

The client presented with a cycle of stress/upper back tightness/decreased core engagement/pelvic floor dysfunction. We all hold our stress/emotions in the fascia of our body – clench our jaw (we are not even aware of it), rounded shoulders, both upper trapezius tightness/ psoas tightness and even pelvic floor clenching. The whole body is connected through fascia. Fascia connects the muscles to muscles, muscles to organs. Postpartum woman goes through not only physical changes but also emotional changes. We all know we need support and it takes a village to raise a kid, but with the pandemic, it was very hard on many women to get the help. It is easy to advise on self care, but some women cannot do it due to lack of support system. On top, the work/home/kids and other stressors increase the stress on their mind and body. Postpartum period is the rebirth of the woman. Woman needs to not only understand the center of gravity of her body but also have to connect emotionally to herself and baby as well. Hormones do help during this time, nature has created solutions for everything, but stress can impact the regulation of hormones. Sleep is another component that gets compromised during the postpartum period which can affect body function. Sleep and rest are very important for digestion, healing, and natural digestive and emotional detox. When we do not sleep well, we lose the strength to help ourselves or support ourselves, many times the body just works on an autopilot mode. Stress can affect breathing mechanics and rib cage mobility. Rib cage can affect the diaphragm function and that can affect the diaphragm and pelvic floor coordination and ultimately pelvic floor function. Once we address the stress and breathing mechanics, the body gets the healing power to melt our fascia and mind and make us feel lighter. The client can connect to her own body and muscles start working. Addressing all these aspects during the postpartum is so vital for women’s physical and emotional health and that can help to prevent future pains and help them to gain confidence. As we hear this a lot, all my aches and pains started after childbirth, I did not know there was help, I pee in my pants with coughing/sneezing that is normal after childbirth.

Case Study Written By: Neha Golwala

My name is Neha Golwala, I am a PT specializing in pelvic health. I work with Zuppa Physical Therapy P.C. in Burnt Hills, NY. I have 14 years of clinical experience in orthopedic and working as a pelvic PT for the last 5 years. I love to work with women during their different phases of life and also chronic pain when there is not much hope. My company website is zuppapt.com and my email is neha.golwala@gmail.com