Sacroiliac Joint dysfunction, Coccydinia, and Dynamic stability of the lumbo-pelvic region Low back pain altered Pelvic Floor function: is there a link? Stability of inter-segmental lumbar motion is reliant on appropriate control of muscle activation by the central nervous system Delayed recruitment of Increased activity of deep local muscles superficial global muscles -Lumbar multifidus -Transversus abdominus -EO / IO -Pelvic floor -Erector spinae -iliopsoas -biceps femoris

Presented by TrA, lower transverse fibres Increase segmental stiffness Compensation due to Dr Barbara Hungerford PhD B.App.Sci (Physio) Internal oblique (OI), deep Co-contract and limit inter-segmental lumbar multifidus & pelvic motion in lumbar spine decreased segmental stability Director : Sydney Spine & Pelvis Centre, Australia floor activate prior to motion : Advanced Manual Therapy Associates (Hodges & Richardson, 1997; Moseley et al, 2002; O’Sullivan et al, 1997) Hides, 94; Hodges & Richardson, 96; Hodges 2003; Radebold 2000

Lumbo-pelvic Stability and optimal load transfer Anatomy of the pubic symphysis Sacroiliac joint articular surface

Lumbo-pelvic region is always interacting with * Fibrocartilaginous gravity joint The SIJ is classified as a * interposed by *diarthroidal synovial joint fibrocartilaginous 65% body weight *hyaline articular cartilage transferred across L5/ disc *synovial capsule S1 in standing * most stable joint in pelvis *6 degrees of freedom Pelvis is the stable platform or hub of the skeleton

Developmental changes of the SIJ articular Factors assisting articular stability at the SIJ Stability of the Pelvic articulations surface & joint cartilage occurs by the 2nd

decade (i.e ridges & grooves) (Vleeming et al, 1990) * Wedge shape of the sacrum * shape of articular surfaces- planar & L-shaped * collagen structure of iliac articular cartilage - Pubic symphysis has L-shaped articular SIJ shape assists load increased friction co-efficient strong ligamentous surfaces at SIJ transfer * complimentary ridges & grooves support Pelvis requires external * passive constraints of surrounding ligaments tensile & compressive forces to stabilise its articulations during weight * SIJ is susceptible to vertical shear loads bearing…. (Snijders et at, 1995; Vleeming et al, 1995)

1 Tonic co-contraction of TrA, pubococcygeus and lumbo- Stability of the Pelvic articulations Stability of the Pelvic articulations sacral multifidus therefore assists stabilisation of intra-pelvic motion for load transfer during weight bearing movements

TrA and pubococcygeus assist stability TrA and pubococcygeus assist stability of pubic of pubic symphysis symphysis TrA activation increases stiffness across SIJ TrA activation increases stiffness Richardson et al 2002 across SIJ (Richardson et al 2002) Lumbosacral multifidus crosses from L5 to PSIS and sacrum, and attaches into posterior SI ligaments (Willard, 2007) Gluteus maximus increases tension across SIJ via attachments into sacrotuberous ligament and posterior layer of thoraco-lumbar fascia Barker et al, 2004

Pelvic Girdle Dysfunction Pelvic Girdle Dysfunction Effect of articular dysfunction at SIJ

1. Articular dysfunction: at 3. Myo-fascial dysfunction: Loss 1. Delay in recruitment of TrA, lumbosacral multifidus, and the pubic symphysis or of functional stability to gluteus maximus maintain pubic symphysis & sacroiliac joint (SIJ) causes 400 ** ** * ** altered joint glide, inability to SIJ alignment during weight 300

maintain closed pack position bearing due to altered motor 200 of SIJ, & altered motor control 100 control (Hungerford et al, 2003;2004) 0 4. Internal derangement of -100 pelvic fascia and organs 2. Ligament injury at either -200 EMG onset relative to motion onset (ms) onset motion to relative onset EMG pubic symphysis or SIJ alters ability to activate pelvic -300 control OI multifidus biceps adductor gluteus gluteus TFL 0 1 2 3 4 5 6 7 8 causes true instability floor muscles femoris longus maximus medius SIJP: symptom atic side

Mean EMG onset for PPGP subjects: symptomatic side ** p ≤ 0.01 Hungerford et al, 2003 * P ≤ 0.05

100 obliquus internus 60

0 % EMG amplitude during Effect of Pelvic Girdle Dysfunction Effect of Pelvic Girdle Dysfunction -60 100 50ms epochs before & multifidus 60 1. Delay in recruitment of TrA and 1. Delay in recruitment of TrA and after initiation of motion 0 % lumbosacral multifidus & gluteus lumbosacral multifidus Hungerford et al,

biceps 100 2003 femoris maximus Hungerford et al, 2003 60

0 % 2. Bracing of EO/IO associated with Control 2. Bracing of EO/IO associated with

-60 decent of pelvic floor (O’Sullivan et al, decent of pelvic floor (O’Sullivan et al, SIJP: 100 2002) 2002) symptomatic adductor 60 longus

0 % -increases IAP 3. Altered activation of

100 pubococcygeus & puborectalis gluteus 60 -Downward pressure onto the bladder maximus makes it more difficult for pubococcygeus 0 %

100 to create the lift required to close the

gluteus 60 medius bladder neck

0 % task) during activity maximal (% activity EMG

tensor fascia 100 lata 60

0 % controls S IJ P : s y m p to m a tic s id e

2 What do we see clinically with articular Pelvic Girdle Dysfunction Ischiococcygeus activity Ischiococcygeus dysfunction? Articular dysfunction at the Augments compression inferior -Decreased ability to activate TrA, lumbosacral multifidus Arises from ischeal spine and with substitution of global muscles such as external sacroiliac joint (SIJ) to SIJ to limit vertical shear anterior aspect of sacrospinous oblique, piriformis, iliopsoas, hamstrings forces on SIJ & substitution ligament, and is directly -Inability to activate pubococcygeus/ puborectalis with pattern for normal PF activity connected to the ligament consequent effect on ability to create a lift of the pelvic floor under the bladder Tonic activity to compress SIJ -over activation of ischiococcygeus, tonically, Ligament injury at either pubic Inserts onto the apex of the sacrum symphysis or SIJ inferiorly and try to limit between S4 & S5, and the lateral is one possible compensation strategy shearing forces across joints border of the coccyx

WHY??? Loss of functional stability Substitution pattern for normal Forms the deep posterior wall of the activity of pubococcygeus? pelvis, in conjunction with piriformis

Ischiococcygeus Optimal pelvic floor contraction: Effect of tonic Ischiococcygeus activity Supplied by ventral rami of the sacral plexus, S3 & S4. • Ischiococcygeus lies in a different plane to levator ani Nerve supply to levator ani (pubococcygeus, puborectalis, • Activation with piriformis may and iliococcygeus) is perineal create an interface that impedes branch of pudendal nerve pudendal nerve mobility through arising from S2-4. the pudendal canal Posterolateral portion of levator ani may take some somatic supply from S3 & S4 • Pain referred to labia, internal sacral nerve plexus vaginal walls, base of scrotum and penis

Pelvic Biomechanics Effect of coccygeus activity on Pelvic Biomechanics Effect of ischiococcygeus overactivity

Flattened lumbar spine

• Sacral apex is drawn into counternutation Counternutated sacrum • Coccyx flexed

3 Effect of ischiococcygeus overactivity Coccydinia: the research Clinical Implications & suggestions

• Often associated with trauma such as a fall, or • Specificity in assessment of pelvic floor muscle MVA activation will assist diagnosis of an over active •2nd most common cause is childbirth, rarely ischiococcygeus related to coccyx fracture (Maigne et al, 96; Peyton, 88) • May also occur after lumbar disc prolapse, or following spinal surgery (Frazier, 1985) • Pts usually describe sacrococcygeal pain that gets worse with sitting, sit to stand, and prolonged standing or bending

Bone stress = “coccyx pain”

Thank you Clinical Implications & suggestions Clinical Implications & suggestions to • Specificity in assessment of pelvic floor muscle activation will • Specificity in assessment of pelvic floor muscle assist diagnosis of an over active ishiococcygeus • An articular dysfunction of the SIJ may create tonic activity of activation will assist diagnosis of an over active isciococcygeus that is recalcitrant to muscle re-education Stephanie Tang, Peta Gosbee, and ishiococcygeus • Be careful of images for pelvic floor that Shreya Ranganathan enhance butt gripping Sydney Spine & Pelvis Physiotherapy Centre, • An articular dysfunction of the SIJ may create Dr James Linklater tonic activity of ischiococcygeus that is • Instead, consider imagery to assist Radiologist, Castlreigh Imaging, North Sydney Orthopedic & Sports Medicine Centre, Crows Nest recalcitrant to muscle re-education. Manual activation of pubococcygeus without Therapy to regain normal articular glide at the ischiococcygeus e.g – Melt your bottom SIJ is required prior to retraining motor – Imagine a triangle from pubic symphysis to Illumination! control. ischeal tuberosities. Imagine that back part of the triangle staying wide as you draw up the front part of the pelvic floor

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