Everyday we as pelvic rehab providers get to help patients achieve their goals by meeting them where they are and guiding them along.
A couple of months ago I had a new patient come in to see me who was seven months status post c-section delivery of her first child. She was referred to physical therapy because she could not tolerate anything touching her lower abdomen and she was also unsure of how to start exercising again including returning to her yoga practice. I remember reading her referral and thinking that this should be a simple evaluation and treatment session. What actually happened was a little different.
Her delivery hadn’t gone the way she planned, and she was not comfortable discussing it at our first session. This patient had not looked at or touched her c-section incision besides drying it off after her shower for the seven months since delivery. Her physician had made a referral to PT and to a counselor within three months of delivery to help support the patients’ recovery. The patient had not followed through with the PT referral until she had significant encouragement from her counselor and physician.
Initially the patient declined any observation or palpation of her abdomen so at our first session we focused on thoracic range of motion, general posture, and encouraged her to start touching her abdomen through her clothes, even if avoiding direct touch to the incisional region. The patient was agreeable with this starting point. At the second session the patient was willing to have me look at her abdomen and touch the abdomen but she declined direct palpation of the scar region. With simple observation I could see a scar that was closed and healing but also that was pulled inferior towards her pubic bone. She was not comfortable laying flat on the treatment table and had to be supported in a semi-recline throughout the session. She also described buzzing symptoms at the scar region when she reached her arms overhead.
We started some gentle desensitization techniques as would be used with a person that had Complex Regional Pain Syndrome (CRPS) after an injury. I focused those treatments to the abdominal region but avoided the scar region. We focused her home program on breathing into her abdomen allowing some stretch and expansion of the abdominal region. Her home program also included laying flat for five minutes per day. I asked her to notice any general tension throughout her body during the day and attempt to change it and release it if able.
By the fourth session we where able to begin direct palpation and manual therapy techniques to the c-section scar and the whole abdominal region. The patient was apprehensive but agreed to proceeding with utilizing techniques as described by Wasserman et al2018 including superficial skin rolling, direct scar mobilization and general petrissage/effleurage of the abdomen and lumbothoracic region.
Over the next five sessions the patient was able to start wearing undergarments and pants that touched her lower abdomen. She was able to perform her own self massage to the region and began an exercise program including prone press ups, progressive generalized trunk strengthening, and return to her prior-to-pregnancy yoga practice.
Drawing on the techniques we learn from multiple sources, applying them to the lumbopelvic region, and helping our patients wherever the client is in their journey to wellness, is what inspires me to keep learning.
Techniques like this are taught in my 2-day Manual Therapy Techniques for the Pelvic Rehab Therapist course. I specifically wrote this course so that pelvic rehab therapists that are looking for more techniques and/or more confidence in their palpation skills would have a weekend to hone those skills. We spend time learning anatomy, learning palpation skills, manual techniques, problem solving home programs and discussing cases. Check out Manual Therapy Techniques for the Pelvic Rehab Therapist - Raleigh, NC - June 22-23, 2019 for more information and I hope to see you there.
Wasserman, J. B., Abraham, K., Massery, M., Chu, J., Farrow, A., & Marcoux, B. C. (2018). Soft Tissue Mobilization Techniques Are Effective in Treating Chronic Pain Following Cesarean Section: A Multicenter Randomized Clinical Trial. Journal of Women’s Health Physical Therapy, 42(3), 111-119.
Birthing can be an unpredictable process for mothers and babies. With cases of fetal distress, the baby can require rapid delivery. Alternatively, in cases with cephalo-pelvic disproportion, the baby has a larger head, or the mother has a decreased capacity within the pelvis to allow the fetus to travel through the birthing canal. Additionally, the baby may have posterior presentation, colloquially known as “sunny side up” in which the baby’s occipital bone is toward the sacrum. With any of these situations, it is good to know c-sections are an option to safely deliver the child.
Women may also be inclined to try to get a c-section to avoid pelvic complication or tears or because of a history of a severe prior tear. As pelvic therapists, we know that the number of vaginal births and history of vaginal tears increase the risk of urinary incontinence and prolapse. Yet, many therapists are unfamiliar with the effects of c-section and the impact of rehab for diastasis.
A 2008 dissection study of 37 cadavers studied the path of the ilioinguinal and Iliohypogastric nerves. The course of the nerves was compared with standard abdominal surgical incisions, including appendectomy, inguinal, pfannestiel incisions (the latter used in cesarean sections). The study concluded that surgical incisions performed below the level of the anterior superior iliac spines (ASIS) carry the risk of injury to the ilioinguinal and iloiohypogastric nerves 1. Another 2005 study reported low transverse fascial incision risk injury to the ilioinguinal and Iliohypogastric nerves, and the pain of entrapment of these nerves may benefit from neurectomy in recalcitrant cases.2
Why does injury to the nerves matter? After pregnancy, patients may need rehab and retraining of their abdominal recruitment patterns for diastasis and stability. The ilioinguinal and Iliohypogastric nerves are the innervation for both the transverse abdominus and the obliques below the umbilicus. When we are working to retrain the muscles, certainly neural entrapment or poor firing can greatly impact the success of our intervention as rehab professionals. Interestingly, a study from Turkey showed patients had a significant increase in diastasis recti abdominis (DRA) with a history of 2 cesarean sections and increased parity and recurrent abdominal surgery increase the risk of DRA.2
A fourth study looked at 23 patients with ilioinguinal and Iliohypogastric nerve entrapment syndrome following transverse lower abdominal incision (such as a c-section). In this study, the diagnostic triad of ilioinguinal and Iliohypogastric nerve entrapment after operation was defined as 1) typical burning or lancinating pain near the incision that radiates to the area supplied by the nerve, 2). Clear evidence of impaired sensory perception of that nerve, and 3) pain relieved by local anaesthetic.4
One of the other symptoms we may see in an area of nerve damage is a small outpouching in the area of decreased innervation on the front lower abdominal wall.
So, what can we do with this information? The good news is that as rehab professionals, we can treat along the fascial pathway of the nerve to release in key areas of entrapment. We can mobilize the nerve directly. Neural tension testing can help us differentiate the nerve in question and we can use neural glides and slides after having freed up the nerve from the area of compression. Then, we can increase the communication of the nerve with the muscles by using specific, localized strengthening and stretch in areas of prior compression. All of these techniques are taught in in our course, Lumbar Nerve Manual Treatment and Assessment. Come join us in San Diego May 3-5, 2019 to learn how to differentially diagnose and treat entrapment of all of the nerves of the lumbar plexus.
Okiemy, G., Ele, N., Odzebe, A. S., Chocolat, R., & Massengo, R. (2008). The ilioinguinal and iliohypogastric nerves. The anatomic bases in preventing postoperative neuropathies after appendectomy, inguinal herniorraphy, caesareans. Le Mali medical, 23(4), 1-4.
Whiteside, J. L., & Barber, M. D. (2005). Ilioinguinal/iliohypogastric neurectomy for management of intractable right lower quadrant pain after cesarean section: a case report. The Journal of reproductive medicine, 50(11), 857-859.
Turan, V., Colluoglu, C., Turkuilmaz, E., & Korucuoglu, U. (2011). Prevalence of diastasis recti abdominis in the population of young multiparous adults in Turkey. Ginekologia polska, 82(11).
Stulz, P., & Pfeiffer, K. M. (1982). Peripheral nerve injuries resulting from common surgical procedures in the lower portion of the abdomen. Archives of Surgery, 117(3), 324-327.