Abstract
Context
Urinary incontinence (UI) in the powerlifting community has been a hot topic due to its noticeability during competition and the burden it places on female athletes who experience it. UI is even experienced in those we least expect: young, high-performing, females with no history of pregnancy. Current studies have utilized primarily survey methodology, thus there is a lack of clinical information on this topic. Furthermore, the top athletes are underrepresentedbecause previous surveys were open to anyone reporting themselves as a powerlifter, regardless of competition level.
Objectives
The objectives of this study were to determine whether UI in elite female powerlifters is correlated with any musculoskeletal diagnoses and to further evaluate potentially contributing factors for UI within this group.
Methods
Subjects underwent an osteopathic structural examination and then completed two surveys: the Incontinence Severity Index (ISI/Sandvik Test for Urinary Incontinence) and the Study Questionnaire.
Results
In total, there were 31 female participants, all of whom were in the top 2 % of powerlifters in the world between the ages of 20 and 30 years old (as of May 21, 2023) and reside in the United States. The survey results displayed a moderately positive relationship between age (rho=0.449, where rho refers to Spearman’s rho), history of pelvic floor examination (rho=0.413), and self-care practice with ISI (rho=0.340). Other survey information such as weight class, height, best total in competition, number of years training, average duration of training day, confidence in ability to contract pelvic floor muscles, history of abdominal or pelvic surgery, history of urinary tract infection (UTI), and sexual activity status all had rho values less than 0.300. With atlantoaxial (AA) rotation to the right, there was an increase in ISI score (p=0.009). Similarly, with AA rotation to the left, there was a decrease in ISI score (p=0.030). All patients with severe ISI had nonphysiologic sacral dysfunctions (p=0.051). Severe ISI-scored participants were more likely to yield a dysfunctional clavicle upon screening (p=0.027). There was a strong correlation between increasing severity of UI and findings of a restricted right clavicle and/or AA rotation to the right (p=0.010). In addition, there were only two individuals with both a restricted right clavicle and AA rotation to the right, and these two individuals both scored severe on the ISI (p=0.012). A pelvic diaphragm dysfunction was present in 74.2 % of the participants. Extension diagnoses of the lumbar spine were found in those with mild UI over those with severe UI (p=0.012). Most other diagnoses were largely unremarkable due to a wide distribution across all ISI scores.
Conclusions
Our study revealed a relationship between UI and somatic dysfunctions in this population. These findings may help providers, especially in the fields of primary care, sports medicine, and urogynecology, to expand treatment options for UI in this group in the future. Survey results yielded a positive relationship of moderate strength between age, history of pelvic floor exination, and engaging in leakage prevention practices with ISI. No survey category was found to have a relationship of high strength with ISI. These findings contribute to our knowledge on factors that do (or do not) contribute to incontinence severity.
Urinary incontinence (UI) has frequently been attributed to pelvic floor muscle weakness. For this reason, it may be surprising that Incontinence Severity Index (ISI) scores in female powerlifters were positively correlated with BMI, age, and competition total in those without a history of childbearing [1], 2]. There are few, if any, studies available that have correlated musculoskeletal dysfunctions alongside incontinence severity, especially in this population. Many previously completed studies regarding this topic included survey methodology only. To better understand UI in this population, we endeavored to correlate somatic dysfunctions identified during musculoskeletal screening with UI severity. Furthermore, we aimed to provide survey data representative of elite female powerlifters who experience UI.
Subjects underwent musculoskeletal screening alongside the Sandvik Test for Urinary Incontinence (ISI) (Supplementary Material) [3]. For the purposes of this study, “elite level” powerlifting is defined as the top 2 % of three-lift totals in each weight class worldwide as of May 21, 2023, as reported by Open Powerlifting. Through this documentation, we strive to increase our information on UI to better treat and prevent UI in powerlifting and nonpowerlifting demographics alike. Furthermore, understanding and treating this phenomenon could help more women stay in the sport, promoting an active lifestyle with regular weight-bearing exercise.
Methods
This study was approved on March 24, 2023 under Proposal Number “PROTOCOL_23_0007” by the Institutional Review Board (IRB) at the University of Pikeville in Pikeville, Kentucky. A Protocol Modification Request was accepted on May 23, 2023. The study was carried out from May 2023 to September 2023. An award of $3,000 from the Kentucky College of Osteopathic Medicine Summer Research Fellowship was accepted by K.N. This study did not include any intervention on participants, and thus no clinical trial registry number is required. Informed consent documents were reviewed with each subject, and signatures were obtained on paper prior to subject participation. The consent process was completed by K.N. Participants were thanked with a $20 gift card at completion.
Study population
In order to be eligible for the study, subjects had to: be female; be 18–30 years of age at enrollment; be in the top 2 % of their respective weight class in the world, as indicated by a total (Table 1) comprised of the athlete’s best squat, bench, and deadlift posted at a sanctioned, drug-tested meet in the raw division; and have a self-reported history of stress UI. Subjects were ineligible if they had a surgery with general anesthesia within 3 months prior to enrollment or a history of pregnancy for 20 weeks or more.
Minimum total posted at a full-sanctioned, drug-tested, raw meet required to participate.
Weight class, kg | Minimum total (squat + bench + deadlift) required to be in top 2 % (in kg)a |
---|---|
43 | 277.5 |
47 | 340.0 |
52 | 367.5 |
57 | 395.0 |
63 | 412.5 |
69 | 432.5 |
76 | 450.0 |
84 | 468.0 |
84+ | 507.5 |
-
aRaw powerlifters may only utilize knee sleeves, wrist wraps, and a belt as assistive equipment.
Subjects were primarily recruited via social media, and there were participants who referred themselves. The study procedure was carried out at gyms and powerlifting meets in the United States.
Musculoskeletal examination design
The musculoskeletal examination design was produced by M.C. and L.G., who trained K.N. to complete the musculoskeletal examination to their standards. All musculoskeletal examinations were completed by K.N. throughout the entirety of the study.
Each subject’s birthday and name was collected; then, each subject was assigned a number and subsequently underwent musculoskeletal screening. The following information was collected: age; height; weight class; diagnosis of occiput on atlas; atlas on axis; cervical spine; thoracic spine; lumbar spine; sacrum; thoracic inlet; ribs; pelvic diaphragm, innominates; scapula; acromioclavicular (AC) joint; sternoclavicular joint; clavicle; radial head; carpals; metacarpals; tibial rotation; fibular head; talar motion; navicular bone; tarsals; metatarsals; external rotators; psoas; quadriceps; hamstring; hip abductors; hip adductors; shoulder range of motion (ROM); scapular motion; flexors of the wrist; extensors of the wrist; and radial/ulnar deviation.
No adverse events were reported.
Survey design
Participants completed two surveys: an ISI form (Supplementary Material) and a Study Questionnaire (Supplementary Material). Surveys were completed after the musculoskeletal examination to preserve objectivity.
Statistical analysis
All statistical tests were performed utilizing Statistical Package for the Social Sciences (SPSS) (IBM, Chicago), version 27. Analysis of variance (ANOVA) tests were utilized to compare the demographic variables within the independent variable of ISI level. Chi-square (χ2) tests were utilized to compare the proportional differences in the dependent variables from the musculoskeletal screening between the independent variables of the ISI level. Spearman’s rho was computed to measure the relationship between the nominal variables. The Spearman’s rho values ranged from −1 to +1, in which −1 indicates a perfectly negative relationship and +1 indicates a perfectly positive relationship. To reduce the risk of Type I error, p<0.05 was considered statistically significant.
Results
After condensing the Open Powerlifting database according to the study inclusion criteria, there were approximately 295 females in the United States who were eligible to take part in the study. To approximate the number of females who might experience UI within this group, we utilized data from a 2021 study that found that approximately 48.8 % of female lifters between the ages of 20 and 70 years old have experienced UI in their lifetime – thereby narrowing our potentially eligible population to 143 [1] (It is also noteworthy that a study in 2019 reported that 41 % of female powerlifters experience UI [4]). Thus, with 31 participants completing this study, we can strongly estimate that these data represent at least 21.7 % of the population of elite female powerlifters who experience UI in the United States, aged 20–30 years old, especially because the exclusion criteria were not applied to this approximation.
The average participant in this study was 24.32 years old at the time of the examination, with the youngest being 20 years old and the oldest 30 years old. The average participant stood at 5 feet, 2 in. (62.91 in.) tall, with the shortest being 5 feet (60 in.) tall and the tallest being 5 feet, 8 in. (70 in.) tall. The average participant also had a best total of 1,037 pounds (470.15 kg) and a history of 8 years participating in resistance training. The median subject participant was in the 152 pound (69 kg) class. The individual with the lowest total was in the 772 pound (350 kg) range, while the highest was over 1,698 pounds (700 kg). Each International Powerlifting Federation (IPF) weight category was represented in the study. The average athlete examined with mild, moderate, and severe UI by ISI was 23.3, 24.3, and 27.3 years old, respectively (p=0.010) (Table 2).
Demographics by incontinence severity index (ISI, n=31).
Mild | Moderate | Severe | p-Value | |
---|---|---|---|---|
Years participated in resistance training, mean | 8.24 | 7.13 | 8.67 | 0.605 |
Mean age at time of examination, years | 23.29 | 24.25 | 27.33 | 0.010 |
Mean weight class | 63.82 | 69.25 | 71.17 | 0.272 |
Mean height, in. | 62.62 | 62.47 | 64.33 | 0.422 |
Mean best total, kg | 470.94 | 458.44 | 483.50 | 0.808 |
Survey
The ISI form (n=31) determined that 17 participants were in the mild category, 8 participants were in the moderate category, and 6 participants were in the severe category of UI.
The vast majority (90.3 %, 28 participants) experienced UI with deadlift, 80.6 % (25 participants) experienced UI with squat, and 6.5 % (2 participants) experienced UI with bench (Table 3). Meanwhile, 19.4 % (6 participants) experienced UI during competition, training, and activities of daily living, while 58.1 % (18 participants) experienced UI in competition and training only. In addition, 19.4 % (6 participants) experienced UI in training only, and 3.2 % (1 participant) experienced UI in competition only.
Survey results (n=31).
Frequency | Percent | |
---|---|---|
Experienced UI during this powerlifting discipline | ||
|
||
Squat only | 2 | 6.5 |
Deadlift only | 6 | 19.4 |
Squat and bench only | 1 | 3.2 |
Squat and deadlift only | 21 | 67.7 |
All disciplines | 1 | 3.2 |
Ever undergone a pelvic floor examination | 3 | 9.7 |
Feels confident that can contract pelvic floor muscles | 25 | 80.6 |
Ever undergone abdominal or pelvic surgery | 2 | 6.5 |
Has a history of urinary tract infections | 9 | 29.0 |
Is sexually active (defined as intercourse in last month) | 25 | 80.6 |
Has any self-care practices to reduce leakage | 9 | 29.0 |
|
||
UI occurs during | ||
|
||
Competition | 1 | 3.2 |
Training | 6 | 19.4 |
Competition and training | 18 | 58.1 |
All the time | 6 | 19.4 |
|
||
Average training day lasts | ||
|
||
Less than 1 h | 0 | 0.0 |
1–2 h | 10 | 32.3 |
2.5–3 h | 17 | 54.8 |
3.5–4 h | 4 | 12.9 |
More than 4 h | 0 | 0.0 |
-
UI, urinary incontinence.
There was only one individual who experienced UI with every discipline, and this person also scored severe on the ISI. All lifters who had experienced UI on the bench press had moderate or severe UI, according to ISI. Every individual with a severe ISI score experienced UI during both squat and deadlift.
Seventeen participants (54.8 %) reported an average training session that lasted between 2.5 and 3 h. Only 3 participants (10 %) had ever had a pelvic floor examination. Twenty-five out of 31 participants felt confident that they could contract their pelvic floor muscles, and the same number of participants reported being sexually active. Meanwhile, 6.5 % of participants (2 participants) had undergone abdominal or pelvic surgery, and 29.0 % (9 participants) had experienced a urinary tract infection (UTI) and an equal percentage reported engaging in leakage prevention practices. Leakage prevention practices included kegels, breathing exercises, and behavioral changes (such as reducing liquids or visiting the bathroom more frequently) that were reported more than once. Less commonly reported practices included physical therapy, “adductor work,” sacroiliac joint release, and abdominal exercises.
There was not a strong relationship between any data from the Study Questionnaire and the ISI. There was a positive relationship of moderate strength between age (rho=0.449), history of a pelvic floor examination (rho=0.413), engaging in leakage prevention practices (rho=0.340), and ISI score. See Table 4 for Spearman’s rho calculation regarding each survey category.
Correlation of Incontinence Severity Index (ISI) with survey categories.
Correlation with Incontinence Severity Index (ISI, Spearman’s rho) | |
---|---|
Age | 0.449 |
Weight class | 0.295 |
Height | 0.110 |
BMI | −0.171 |
Best total | 0.071 |
Years participating in resistance training | −0.030 |
Average training day length | −0.023 |
History of pelvic floor examination | 0.413 |
Confidence in ability to contract pelvic floor muscles | 0.030 |
History of abdominal or pelvic surgery | 0.090 |
History of urinary tract infections | 0.119 |
Sexually active | 0.046 |
Does self-care practices to attempt to improve urine leakage | 0.340 |
-
BMI, body mass index.
Musculoskeletal examination (n=31)
Axial skeleton
Atlantoaxial (AA) rotation to the right was associated with increased UI severity (p=0.009). Conversely, AA rotation to the left was associated with lower UI severity (p=0.030). This is evidenced by 1, 2, and 4 participants presenting with rotation to the right at the AA joint, and by 15, 6, and 2 participants presenting with rotation to the left at the AA joint in the mild, moderate, and severe ISI groups, respectively.
The occiput on atlas (OA) and cervical screening results were statistically insignificant.
Eighteen participants (58 %) exhibited somatic dysfunctions that included a level or multiple levels within the T12 to L2 region; this area is relevant because it is the location of viscerosomatic reflexes for the lower third of the ureters, bladder, lower fallopian tubes, and uterus [5]. Among the participants, 55 % exhibited somatic dysfunctions that included a level or multiple levels within the T5–T9 region; this area contains the nerves that provide sympathetic innervation to the foregut including the liver, gallbladder, proximal duodenum, stomach, spleen, and pancreas.
Left inhaled rib(s) anywhere within the region of ribs 2–10 were more common in those with a mild ISI score, with 10 out of 17 patients in this group exhibiting this dysfunction as opposed to 1 out of 8 and 2 out of 6 reflected in the moderate and severe groups, respectively (p=0.081). All other rib diagnoses were not significant.
The most common lumbar diagnosis location was L3. Thirteen individuals had a dysfunction at this level, including Type I and Type II dysfunctions. No one with severe UI exhibited an extended lumbar diagnosis, whereas 11 out of 17 and 2 out of 6 participants in the mild and moderate ISI groups did present with extended lumbar dysfunctions, respectively (p=0.012). Common compensatory pattern (CCP) of the lumbar spine was more common in the severe UI group, with 2 out of 6 (33 %) of the severe UI group having lumbar CCP and only 1 out of 8 and 0 out of 17 individuals in the mild and moderate groups presenting with lumbar CCP, respectively (p=0.057). It is important to note that this statistic may be irrelevant, given that only 3 individuals out of the 31 total had presented with a left-on-left sacrum (sacral CPP) in the first place.
All patients with severe ISI had nonphysiologic sacral dysfunctions (6 out of 6), and physiologic sacral diagnoses were present in the mild and moderate UI groups (1 out of 17 and 3 out of 8, respectively; p=0.051). Left unilateral flexion was the single most common sacral diagnosis, with 12 out of 31 participants exhibiting this dysfunction. See Table 5 for more information on this region.
Musculoskeletal findings by Incontinence Severity Index (ISI).
Mild (n=17) | Moderate (n=8) | Severe (n=6) | p-Value | |
---|---|---|---|---|
AA joint (rotation) | ||||
|
||||
RR | 1 (5.9 %) | 2 (25.0 %) | 4 (66.7 %) | 0.009 |
RL | 15 (88.2 %) | 6 (75.0 %) | 2 (33.3 %) | 0.030 |
No dysfunction | 1 (5.9 %) | 0 (0.0 %) | 0 (0.0 %) | 0.653 |
|
||||
Shoulder: AC joints | ||||
|
||||
R restricted | 3 (17.6 %) | 1 (12.5 %) | 3 (50.0 %) | 0.194 |
L restricted | 4 (23.5 %) | 0 (0.0 %) | 1 (16.7 %) | 0.328 |
No dysfunction | 9 (52.9 %) | 7 (87.5 %) | 1 (16.7 %) | 0.030 |
|
||||
Shoulder: clavicle | ||||
|
||||
R restricted | 4 (23.5 %) | 1 (12.5 %) | 4 (66.7 %) | 0.066 |
L restricted | 5 (29.4 %) | 0 (0.0 %) | 1 (16.7 %) | 0.218 |
No dysfunction | 8 (47.1 %) | 7 (87.5 %) | 1 (16.7 %) | 0.027 |
|
||||
Further evaluation of clavicle and AA joint | ||||
|
||||
Individuals with either restricted right clavicle and/or AA rotation to the right | 5 (29.4 %) | 3 (37.5 %) | 6 (100 %) | 0.010 |
Individuals with both a restricted right clavicle and AA rotation to the right | 0 (0.0 %) | 0 (0.0 %) | 2 (33.3 %) | 0.012 |
|
||||
Lumbar diagnoses (any level) | ||||
|
||||
ESRR | 3 (17.6 %) | 1 (12.5 %) | 0 (0.0 %) | 0.541 |
FSRR | 2 (11.8 %) | 1 (12.5 %) | 2 (33.3 %) | 0.443 |
ESRL | 8 (47.1 %) | 1 (12.5 %) | 0 (0.0 %) | 0.045 |
FSRL | 3 (17.6 %) | 3 (37.5 %) | 2 (33.3 %) | 0.512 |
NSLRR | 0 (0.0 %) | 1 (12.5 %) | 2 (33.3 %) | 0.057 |
NSRRL | 1 (5.9 %) | 1 (12.5 %) | 0 (0.0 %) | 0.635 |
No dysfunction | 0 (0.0 %) | 0 (0.0 %) | 0 (0.0 %) | – |
|
||||
Sacral diagnosis | ||||
|
||||
LoL | 0 (0.0 %) | 3 (37.5 %) | 0 (0.0 %) | 0.008 |
RoR | 1 (5.9 %) | 0 (0.0 %) | 0 (0.0 %) | 0.653 |
LoR | 4 (23.5 %) | 2 (25.0 %) | 2 (33.3 %) | 0.893 |
RoL | 0 (0.0 %) | 0 (0.0 %) | 0 (0.0 %) | – |
R uni. flex. | 2 (11.8 %) | 0 (0.0 %) | 0 (0.0 %) | 0.415 |
R uni. ext. | 2 (11.8 %) | 1 (12.5 %) | 1 (16.7 %) | 0.953 |
L uni. flex. | 7 (41.2 %) | 2 (25.0 %) | 3 (50.0 %) | 0.607 |
L uni. ext. | 1 (5.9 %) | 0 (0.0 %) | 0 (0.0 %) | 0.653 |
|
||||
Further evaluation of sacral diagnosis | ||||
|
||||
Physiologic diagnosis (LoL or RoR) | 1 (5.9 %) | 3 (37.5 %) | 0 (0.0 %) | 0.051 |
|
||||
ASIS/PSIS/pubic symphysis | ||||
|
||||
R anterior | 5 (29.4 %) | 2 (25.0 %) | 1 (16.7 %) | 0.827 |
L anterior | 1 (5.9 %) | 2 (25.0 %) | 0 (0.0 %) | 0.215 |
R posterior | 0 (0.0 %) | 1 (12.5 %) | 0 (0.0 %) | 0.226 |
L posterior | 6 (35.3 %) | 3 (37.5 %) | 0 (0.0 %) | 0.217 |
R shear | 2 (11.8 %) | 0 (0.0 %) | 3 (50.0 %) | 0.032 |
L shear | 3 (17.6 %) | 0 (0.0 %) | 1 (16.7 %) | 0.449 |
No dysfunction | 0 (0.0 %) | 0 (0.0 %) | 1 (16.7 %) | 0.116 |
|
||||
Pelvic diaphragm | ||||
|
||||
No restriction | 4 (23.5 %) | 2 (25.0 %) | 2 (33.3 %) | 0.893 |
R restricted | 9 (52.9 %) | 6 (75.0 %) | 2 (33.3 %) | 0.293 |
L restricted | 4 (23.5 %) | 0 (0.0 %) | 2 (33.3 %) | 0.239 |
-
AA, atlantoaxial; AC, acromioclavicular; ASIS, anterior superior iliac spine; PSIS, posterior superior iliac spine.
Appendicular skeleton
Those with severe UI were more likely to be diagnosed with restricted acromioclavicular (AC) joints, as represented by only 1 individual in the severe group presenting without AC joint dysfunction vs. 9 and 7 individuals in the mild and moderate groups, respectively (p=0.030). Note that one individual with mild UI and one individual with severe UI did not have their AC or SC joint screening results recorded, as reflected in the previously mentioned statement.
Participants with severe UI were also much more likely to have a restricted clavicle, as reflected by 8 out of 17, 7 out of 8, and 1 out of 6 participants in the mild, moderate, and severe categories, respectively, presenting with no clavicular dysfunction on screening (p=0.027). Laterality was appreciated, with 4 participants, or 66.7 %, of the severe UI group presenting with a right restricted clavicle, as opposed to 4 participants (23.5 %) and 1 participant (12.5 %) in the mild and moderate groups, respectively (p=0.066).
A total of 30 out of 31 participants had a radial head dysfunction, and an anterior radial head dysfunction was more common than a posterior radial head dysfunction, as 25 out of those 30 individuals presented with an anterior radial head on examination. Other areas of evaluation in the appendicular skeleton yielded high variability.
Further evaluation
There was a strong relationship between increasing severity of UI and findings of a restricted right clavicle and/or AA rotation to the right, with 5 out of 17 individuals with mild UI, 3 out of 8 individuals with moderate UI, and 6 out of 6 participants with severe UI presenting with either of these dysfunctions (p=0.010). In addition, there were only two individuals in the entire study with both a restricted right clavicle and AA rotation to the right; both of these individuals were in the severe ISI group (p=0.012).
Muscles
Nearly three-quarters (74.2 %, or 23 out of 31) of all participants had a pelvic diaphragm dysfunction. No particular ISI group was more or less likely than the others to have a pelvic diaphragm dysfunction, with 13 out of 17, 6 out of 8, and 4 out of 6 participants in the mild, moderate, and severe categories, respectively, presenting with a pelvic diaphragm dysfunction (p=0.893).
Greater than or equal to 77.4 % of participants had each of the following:
One or more hypertonic external rotator muscles (25 out of 31 participants)
One or more hypertonic psoas muscles on examination (25 out of 31 participants)
One or more hypertonic hamstring muscles (24 out of 31 participants).
Every lifter with a severe ISI score had at least one hypertonic external rotator on examination; 14 out of 17 and 5 out of 8 participants in the mild and moderate groups, respectively, also had at least one hypertonic external rotator on examination.
Those with abductor hypertonicity (13 out of 31) and adductor hypertonicity (15 out of 31) had a preference of hypertonicity on the right side: 11 out of the 13 individuals with abductor hypertonicity and 11 out of 15 of the individuals with adductor hypertonicity had hypertonicity on the right side.
With increasing ISI score, there was an increasing percentage of individuals with a flexed left wrist, with 1 out of 17, 2 out of 8, and 3 out of 6 individuals in the mild, moderate, and severe UI groups having a flexed left wrist on examination, respectively (p=0.056).
Exactly half of each of the moderate and severe UI groups had dysfunctional/limited shoulder ROM on examination. In addition, 9 out of 17 (52.9 %) individuals in the mild UI group also displayed dysfunctional shoulder ROM. The remaining muscular examination results were largely unremarkable due to their wide range of presentation. The presence or absence of any muscle hypertonicity was not correlated with worsening ISI score.
Discussion
Pelvic diaphragm dysfunction has been a popular focus of treatment in recent years regarding UI, and rightfully so, given that such a large percentage of the study group had pelvic diaphragm dysfunctions. Furthermore, it has already been shown that both hypertonicity and hypotonicity of the pelvic floor muscles have negative impacts on the urinary system [6], 7]. However, is the pelvic region the only useful part of the body to focus on when treating UI? Our study suggests that there are areas of the body that are more reflective of UI severity than the pelvic floor and should be considered when providing treatments to this group.
Given the results found at the AA joint and its rotational relationship to increasing and decreasing UI severity, the vagus nerve became an area of interest given its proximity to the joint and role in the parasympathetic system. The vagus nerve’s mechanism of communication with the lower body is not completely clear, but its relationship has recently been demonstrated in some studies.
Researchers in a 2019 study found that stimulating the sacral nerves in rats resulted in vagus nerve activity, as proven with heart rate variability analysis and increased plasma pancreatic polypeptide levels in rats that received sacral nerve stimulation, as compared to the control group, among other parameters [6].
Furthermore, a 2023 study found that the vagus nerves in humans actually contain sympathetic efferent fibers in addition to their parasympathetic fibers; these sympathetic fibers are present further caudally on the right side than the left [7]. This sympathetic feedback on the left, then, would be coming from a more proximal vagal target like the heart, and the sympathetic feedback on the right vagus nerve would receive sympathetic feedback from a more distal vagal target, such as the colon. This explains one mechanism in which the vagus nerve can communicate with the lower autonomic system as it pertains to waste removal from the body.
It is possible that UI severity and its concordance with the AA joint rotation may be further evidence of the broad-reaching effects of the vagus nerve and its probable functional relationship to the sacral plexus.
The spinal accessory nerve and vagus nerve exit the skull through the jugular foramen, sharing an arachnoid and dural sheath before the accessory nerve diverts posteriorly behind the cervical column and the vagus nerve continues anteriorly, both running in close proximity to the AA joint [8]. Given their proximity and shared meninges, the relationship between the vagus nerve and accessory nerve could also explain why both AA rotation and clavicular restriction were found together to be correlated with UI severity. Remember that the accessory nerve innervates the sternocleidomastoid muscle, which attaches directly to the clavicle.
For these reasons, it may be worth treating this area and monitoring for improvement in those who experience UI.
The sacrum is another potential area of targeted treatment, given that all subjects with severe UI had nonphysiologic sacral diagnoses. All lifters with severe UI having at least one hypertonic external rotator support this, given that the piriformis muscle (major external rotator of the leg) attaches on the anterior, inferior portion of the sacrum and could result in backward torsions or sacral extensions with its hypertonicity.
The lack of a physiologic sacral diagnosis (forward torsions) in those with severe UI alongside the lack of an extended lumbar diagnosis raises the question of whether this severity could be related to bracing and the Valsalva maneuver. If athletes are bracing more with their lower abdominal muscles and pelvic floor instead of pushing into their upper abdomen, this could explain these findings alongside severe UI in this population. For this reason, it may be worthwhile for athletes to be evaluated for proper bracing technique.
Survey results regarding increasing competition total, athlete confidence in contracting their pelvic floor muscles, body mass index (BMI), and history of a pelvic floor examination, and their relationship to ISI, did not align with those found in Wikander’s studies [1], 2]. This difference may be attributed to the difference between Wikander’s population (all competition levels and a larger sample size) and our study’s population (elite lifters only and a smaller sample size) [1], 2]. These results indicate that Wikander’s survey findings are not reflected within the elite population, with the exception of increasing age having a positive relation of moderate strength with increasing ISI (rho=0.449) [1], 2].
It is recommended that providers, especially those in primary care and sports medicine, be attentive to the somatic dysfunctions found to be significant when treating young powerlifters with complaints of UI. Because a study of this nature is so unique, it may be worth looking for these somatic dysfunctions in broader populations who experience UI, especially if they meet any of the same demographic categories as this population studied.
Limitations
Survey results were reported based on participant memory, which has the potential to skew results. Some athletes were screened within one day of competition, which could yield dysfunctions that are not typically present at baseline. The musculoskeletal examiner was a student; the Doctors of Osteopathic Medicine (DOs) overseeing the study evaluated the student’s skills ahead of time to ensure a proficient level of performance that would lead to consistency in examination. Having one evaluator of examinations was another way that we intentionally limited variability and supported the reliability of the findings.
Although these limitations are to be considered, this study adds valuable and novel information to the neurological and sports medicine fields of research.
Conclusions
Incontinence severity was found to be associated with certain somatic dysfunctions in elite female powerlifters, aged 20–30 years old. AA joint rotation to the right was associated with increased UI severity. AA joint rotation to the left was associated with decreased UI severity. Nonphysiologic sacral dysfunctions, nonextended lumbar spine dysfunctions, clavicular restriction, restriction of the right clavicle in conjunction with AA joint rotated right, and AC joint restriction were also statistically significant findings in those with a severe ISI score. The survey results displayed a positive relationship of moderate strength between age, history of pelvic floor examination, and engaging in leakage prevention practices with ISI. Treatment of these somatic dysfunctions should be considered in this population.
Funding source: Kentucky College of Osteopathic Medicine Summer Research Fellowship
Acknowledgments
The authors would like to thank the Kentucky College of Osteopathic Medicine and their Summer Research Fellowship for supporting this project; Meg Wright Sidle, PhD (Statistician for the University of Pikeville) for completing the data analysis for the study; and to the OpenPowerlifting Data Service for supplying public powerlifting data for research purposes.
-
Research ethics: This study was approved on March 24, 2023 under Proposal Number “PROTOCOL_23_0007” by the Institutional Review Board (IRB) at the University of Pikeville in Pikeville, Kentucky. A Protocol Modification Request was accepted on May 23, 2023. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).
-
Informed consent: Informed consent was obtained from all individuals included in this study.
-
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
-
Use of Large Language Models, AI and Machine Learning Tools: None declared.
-
Conflict of interest: None declared.
-
Research funding: An award of $3,000 from the Kentucky College of Osteopathic Medicine Summer Research Fellowship was accepted by K.N.
-
Data availability: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
References
1. Wikander, L, Kirshbaum, MN, Waheed, N, Gahreman, DE. Urinary incontinence in competitive women powerlifters: a cross-sectional survey. Sports Med Open 2021;7:89. https://doi.org/10.1186/s40798-021-00387-7.Suche in Google Scholar PubMed PubMed Central
2. Wikander, L, Kirshbaum, MN, Waheed, N, Gahreman, DE. Association between obstetric history and urinary incontinence in a cohort of resistance-trained women. Int J Womens Health 2022;14:1211–18. https://doi.org/10.2147/IJWH.S367110.Suche in Google Scholar PubMed PubMed Central
3. Sandvik, H, Hunskaar, S, Seim, A, Hermstad, R, Vanvik, A, Bratt, H. Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey. J Epidemiol Community Health 1993;47:497–9. https://doi.org/10.1136/jech.47.6.497.Suche in Google Scholar PubMed PubMed Central
4. Wikander, L, Cross, D, Gahreman, DE. Prevalence of urinary incontinence in women powerlifters: a pilot study. Int Urogynecol J 2019;30:2031–9. https://doi.org/10.1007/s00192-019-03870-8.Suche in Google Scholar PubMed
5. Seffinger, MA. Foundations of osteopathic medicine: philosophy, science, clinical applications, and research, 4th ed. Wolters Kluwer; 2018.Suche in Google Scholar
6. Huang, Z, Li, S, Foreman, RD, Yin, J, Dai, N, Chen, JDZ. Sacral nerve stimulation with appropriate parameters improves constipation in rats by enhancing colon motility mediated via the autonomic-cholinergic mechanisms. Am J Physiol Gastrointest Liver Physiol 2019;317:G609–17. https://doi.org/10.1152/ajpgi.00150.2018.Suche in Google Scholar PubMed PubMed Central
7. Ruigrok, TJH, Mantel, SA, Orlandini, L, de Knegt, C, Vincent, AJPE, Spoor, JKH. Sympathetic components in left and right human cervical vagus nerve: implications for vagus nerve stimulation. Front Neuroanat 2023;17:1205660. https://doi.org/10.3389/fnana.2023.1205660.Suche in Google Scholar PubMed PubMed Central
8. Standring, S. Gray’s anatomy: the anatomical basis of clinical practice. London: Churchill Livingstone-Elsevier; 2008:458 p.Suche in Google Scholar
Supplementary Material
This article contains supplementary material (https://doi.org/10.1515/jom-2024-0079).
© 2024 the author(s), published by De Gruyter, Berlin/Boston
This work is licensed under the Creative Commons Attribution 4.0 International License.
Artikel in diesem Heft
- Frontmatter
- General
- Original Article
- Determining the effects of social media engagement on surgery residents within the American College of Osteopathic Surgeons
- Medical Education
- Commentary
- Pioneering the future: incorporating lifestyle medicine tools in osteopathic medical education
- Musculoskeletal Medicine and Pain
- Original Article
- Urinary incontinence in elite female powerlifters aged 20–30: correlating musculoskeletal exam data with incontinence severity index and survey data
- Neuromusculoskeletal Medicine (OMT)
- Original Article
- Effects of a single osteopathic manipulative treatment on intraocular pressure reduction: a pilot study
- Public Health and Primary Care
- Original Article
- Impact of a clinician-directed educational program on communicating with patients regarding gun violence at two community urban healthcare centers
- Clinical Image
- Pityriasis lichenoides chronica presenting in skin of color
Artikel in diesem Heft
- Frontmatter
- General
- Original Article
- Determining the effects of social media engagement on surgery residents within the American College of Osteopathic Surgeons
- Medical Education
- Commentary
- Pioneering the future: incorporating lifestyle medicine tools in osteopathic medical education
- Musculoskeletal Medicine and Pain
- Original Article
- Urinary incontinence in elite female powerlifters aged 20–30: correlating musculoskeletal exam data with incontinence severity index and survey data
- Neuromusculoskeletal Medicine (OMT)
- Original Article
- Effects of a single osteopathic manipulative treatment on intraocular pressure reduction: a pilot study
- Public Health and Primary Care
- Original Article
- Impact of a clinician-directed educational program on communicating with patients regarding gun violence at two community urban healthcare centers
- Clinical Image
- Pityriasis lichenoides chronica presenting in skin of color