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Home , Abdominal wall, Levator ani, Linea alba (abdomen), Pelvic floor

4/1/2018

The In Orthopedic Physical Therapy Sarah Dominguez, PT, MSPT, CLT, WCS, CMTPT

No Disclosures

Objectives

1. Understand the function of the pelvic floor in functional tasks such as walking, squatting, running, step up. 2. Understand how to consider the pelvic floor as a potential problem in spine, SIJ and hip disorders. 3. Know how to screen for pelvic floor and when to refer to a Pelvic Floor PT. 4. Learn several treatment ideas to implement in addressing the pelvic floor in orthopedic rehabilitation.

1 4/1/2018

What is the Pelvic Floor? • Group of muscles in the base of the • Works alongside the Abdominal, hip and spinal musculature • Coordinates with the Diaphragm to control intra- abdominal pressures

Pelvic floor musculature

• Bulbospongiosus, Ischiocavernosus, transverse perineal most superficial • Urethral sphincter, urethrovaginalis, deep transverse perineal second layer • Illiococcygeus, coccygeus, puborectalis, pubo-coccygeus (), and obturator internus make the deepest layer

Pelvic Floor Superficial layers • Ischiocavernosus, bulbospongiosus, transverse perineal, deep transverse perineal, urethral sphincter, urethrovaginalis, (EAS) • Share common attachments at perineal body • Provide more Sphincteric action

2 4/1/2018

Pelvic Floor Levator ani group

• Deepest layer of the pelvic floor muscles • Iliococcygeus, ischiococcygeus, puborectalis, pubococcygeus, • Share tendinous attachments with obturator internus (hip ER) • Attach at , ileum, and

Pelvic floor muscles • Type 1 and Type 2 fibers exist • Genetic factors and race influence the percentage of each type per person. Studies show that specific training can convert type 1 to type 2 and vice versa • Pelvic Floor is typically 70-80% Slow twitch (type 1) and 20-30% Fast twitch (type 2) • Fast twitch are found in higher percentage around the and • Must maintain an active resting tone for continence • Must respond reflexively to prevent incontinence

Functions of the Pelvic Floor

• Supportive • Sphincteric • Sexual • Stability • Sump Pump (venous/lymphatic)

3 4/1/2018

Pelvic Floor Mechanics

• Concentric Contraction: Produces a squeeze and a lift • close vaginal, urethral and anal openings • bring ischial tuberosity together • counter-nutating • bring tailbone toward pubic bone • Eccentric Contraction • Opens urethra, anal and • Levator plate descends • Allows for normal function of bowel and bladder empty • Important in gait and running

Pelvic floor as part of the functional system

• Pelvic floor is a primary stabilizer for the pelvic girdle • Functions alongside local and global muscles for optimal motor control • Just doing Kegel exercises isn’t addressing the issue • Movement pattern compensations require us to consider the pelvic floor activity or inactivity as part of the puzzle

4 4/1/2018

Pelvic floor as part of the functional system

• PFM has direct connection with Obturator internus through tendinous attachments. • It contributes to local hip control and stabilizes hip with work by the larger global muscles • Play a role in anchoring deep hip rotators and provide good hip joint mechanics and allow optimal power for the larger muscles

Activity!

• Palpate Posterior sling in stand with pelvic floor contraction • Palpate Obturator Internus in side lying

5 4/1/2018

Note Fascial attachments from Diaphragm to Pelvic Floor Through: Quadratus Lumborum Psoas Iliacus Obturator Internus

The Amazing Diaphragm

• Note how far into the thoracic cavity the diaphragm goes. The core really starts in mid-thoracic range and runs to pelvic floor.

Diaphragm attachments • Xyphoid process • Internal surfaces of lower 6 ribs • Lumbar spine • Arcuate arch over psoas and quadratus lumborum

6 4/1/2018

Diaphragmatic assistance with trunk control

• Contributes to trunk control • Resting tone increased prior to peripheral movements • Tonically active with sustained activity • Modulates activity with respiration during peripheral activities

Coordination of diaphragm and TrA

• TrA and diaphragm activity linked with opposing patterns • TrA activity increases with expiration while diaphragm activity decreases • TrA activity decreases with inspiration while diaphragm activity increases

Coordination of Pelvic Floor and diaphragm

• Inhale: • Diaphragm actively contracts, and pulls down, expanding rib cage and belly • Pelvic Floor relaxes and descends • Exhale: • Diaphragm relaxes up, rib cage contracts, abdominals contract • Pelvic floor contracts and lifts

7 4/1/2018

Transversus Abdominus • Deepest abdominal muscle • Arises from , iliac crest, thoracolumbar , and inner surfaces of lower 6 ribs • Attaches into fascial plane of rectus abdominus and • Fibers of upper, middle, and lower sections of TrA lay at different orientations • Superior fibers lay superiomedially • Middle and inferior fibers lay inferiomedially at slightly different angles

Internal oblique

• Lies between TrA and EO • Arises from iliac crest, inguinal ligament, and thoracolumbar fascia inferior to L3 • Attach to 7-10th ribs at costochondral joints and tips of 11-12th ribs • Blend into to rectus fascia and into linea alba to pubic crest • Fibers are generally oriented in superiomedial plane • Over activity of IO presents with increased inferior rib angle or rib flaring

External oblique • Largest abdominal muscle • Arises from lower 8 ribs • Interdigitates with serratus anterior and latissimus dorsi, possible attachments onto thoracolumbar fascia • Attach onto anterior iliac crest • Blend to rectus fascia and into linea alba • Fibers run generally inferomedially • Over activity presents with rigidity of rib cage or acute inferior rib angle

8 4/1/2018

Rectus abdominus

• Arises from pubic crest and of • Inserts into 5-7 costal cartilage and xyphoid process • Enclosed in fascial sheath formed by of TrA, EO and IO • Medial borders of RA connect via the linea alba, a strong fascial sheath

Activity

• Palpate rib angle: Acute? Obtuse? Just right? • Palpate Diaphragm with breathing

Multifidus • Superficial fibers • Insert 3 vertebral levels below origin • Deep fibers • In pelvis, attaches to deep levels of thoracolumbar fascia of raphe of glut max • Connect into capsule of SIJ • Blends with Sacrotuberous ligament • More Type I fibers than Type II

9 4/1/2018

Thoracolumbar fascia

• Critical structure for load transfer between trunk and lower extremities • Contains alpha-smooth muscle actin called myoblasts with contractile capability • Tension is transmitted to ligamentum flavum and assists with lumbar alignment

Bony and fibrous attachments of thoracolumbar fascia

Bony attachments Fibrous attachments • Iliac crest • Ligamentum flavum • PSIS • Iliolumbar ligament • Posterior sacrum • Supraspinal ligament • Sacrotuberous ligament

Muscle attachments of thoracolumbar fascia

• Transverse abdominus • Biceps femorus • Internal oblique • Quadratus lumborum • External oblique • Lower trap • Glut max • Multifidus • Latissimus dorsi • Erector spinae

10 4/1/2018

Palpate Multifidus

• Palpate just lateral to sp’s and deep • Feel muscle swell into thumbs • Ask For Pelvic Floor contraction • Have them raise their arm

Pelvic Floor Role in trunk and pelvic stability

• Plays a role in feedforward and feedback mechanism of Lumbopelvic stability • Contributes to force closure of the SIJ and controls motion of the sacrum relative to the ilia • SIJ stiffness • Sacral counternutation • Contributes to control of Intra-abdominal Pressures (IAP) and tension in the thoracolumbar fascia

PFM coordination with trunk musculature

• Studies show PFM to be coordinated with • PFM fire first, prior to abdominal wall and spinal mm. • Must contract to control IAP, but must have coordinated effort of TRA, Lumbar multifidus to provide stability with mobility of the trunk. • Dysfunction in the PFM leads to poor anchor at sacrum, tailbone and ilia for the rest of the system.

11 4/1/2018

Pelvic Floor response to varying postures

• Capson et al, 2011 • N = 16 nulliparous, 22-41 yo • EMG recorded in stand, cough, valsalva, MVC and load-catching task with hyperlordosis, neutral and hypolordosis • Higher tone in PFM in stand and hypolordotic postures • Increased peak strength in hypolordotic postures for all tasks • Posture influences both contractility and power for static and dynamic tasks • Posture did not influence PFM timing for the tasks

Pelvic Floor Activity with Curl UP

Study by Barton, et al (2015) • 90 women in exercise class • Transabdominal US scan of PFM and Bladder • 25% (n=23 women) could not produce an appropriate lift of the Pelvic Floor • ALL 90 displayed descent of the bladder • 60% had Stress

What should we see with Curl Up? • Rib angle remains the same • Abdominal wall flattens (no doming) • Pelvis remains neutral (no posterior tilt)

12 4/1/2018

PFM Activity with Active Straight Leg Raise

• Sjodahl, et al. • 16 women with PGP and 11 pain free women • sEMG recordings of PFM and Abdominal wall during ASLR • Pre-activation of PFM occurred in 91% of pain free women and only 36% of women with PGP • Women with PGP have a delated onset in both PFM and Abdominal wall recruitment • PFM should have feed forward mechanism for pelvic girdle stability

What should we see with ASLR? • Observe symmetry, abdominal wall, rib angle, pelvis • Ask patient if there is a difference • Apply pressure to determine where the issue maybe

PFM Activity in limb movements

• Sjodahl, et. Al • N=10 parous women, no c/o lumbopelvic pain • sEMG recordings of PFM, TrA, IO, RA, ES, Hip Add, RF and Deltoid • Performed Supine leg lift and Standing arm lift • PFM activity onset before initiation of movement of the limb, coordinated with abdominal wall • Feedforward response of the PFM

13 4/1/2018

PFM Activity with Running

• Leightner, et al (2017) • sEMG of PFM during TM running at 7, 11 and 15 km/hr. • Found a pre-emptive contraction PFM just before Heel strike • Found a reflexive eccentric lengthening during stance

PFM activity with running in incontinent women • Marques (2010) found in incontinent women show a delay between stimulus and contraction of PFM • Leitner(2016) examined 22 SUI and 28 continent women • PFM activity increased with speed • Likely rising ground reaction forces causing higher force demands for PFM • Women with SUI had increased PFM activity vs. controls

Pelvic floor function in UI women

• Smith et al found incontinent women to have increased PFM and EO activity with postural challenges compared to continent women • May over recruit PFM to prevent leaks, which contributes to poor motor control and compensatory movements • Chronic overuse does not allow pelvic-hip relationship to move with optimal mechanics.

14 4/1/2018

Load Transfer Activity

• Examine weight shift and single leg stance • Assess for SIJ force closure • Observe trunk, hip rotation, trendelenberg • Observe knee and foot • Ask for a pelvic floor contraction prior to movement. Does this change anything?

How can sports med PT consider PFM as a contributor?

ASK - are you aware of your pelvic floor during that task? - Do you leak with the task? OBSERVE - movement patterns for the task - consider PFM relationships with trunk, hip and abdominals EDUCATE - Neutral spine/pelvis - coordination with breath - proper function of PFM/Core system

Pelvic floor referral patterns; Torstensson, et. al

15 4/1/2018

Posture

• Posterior pelvic tilt • Slouchy, weak posture • Toe out • Abdominal Bracing/sucking in • Anterior pelvic tilt • Position of femur relative to ilia • Position of Pelvis and Rib Rings in Transverse plane

Functional Movements

• Squat • Rib rings • Pelvic ring • Pelvic tilt • Knee posture • Trunk posture • Single leg squat • Pelvic ring • Trunk posture • Knee posture

Observe and Palpate!

• Supine Pelvic Floor Contraction and what happens at the abdominal wall • Prone Pelvic Floor contraction, palpate coccyx for movement • Palpate during recruitment • Watch Rib angle with recruitment • Squat mechanics • Overhead reach

16 4/1/2018

Case Example

• 30 yo female 2 years s/p L hip labral repair • Previous runner, yogi, very active with 2 small children • Has completely stopped all activity due to fear of worsening/ruining hip surgery and pain. • Previous PT for 18 months post surgery • Pain L buttock, ischial tuberosity into vagina and anterior groin

Findings

• Fear of activity • Pain with passive hip flexion past 90d, IR to end range • Positive FADDIR • Dec’d hip IR L vs. R • Diastasis Rectus Abdominus 2 fingers above and below umbilicus with poor fascial compliance • Poor abdominal wall recruitment patterns with overuse RA and obtuse rib angle at rest • Pain with palpation Obturator internus • Significant hip drop with single leg stance and weight shift

Where to begin treatment?

• Educate about pain • Neutral Spine • Local first then global • Selective recruitment exercises help reorganize motor control patterns in central cortex to improve muscle recruitment patterns (Liebenson) • Diaphragmatic breathing improves core stability (Akuthota)

17 4/1/2018

• What does literature tell us?

• There is no ONE RIGHT ANSWER . Train for the task, utilize many different techniques for dynamic stability phase, but research is very conclusive that we must progress from Neuromotor phase to stability phase to dynamic phase.

Verbal Cues to recruit pelvic Floor

• Women • Like stopping stream of urine • Imagine you are picking up a blueberry with your vagina • Men • Like stopping stream of urine • Lift up family jewels, pull the turtle head back into its shell

18 4/1/2018

Correct Pelvic Brace

• Can feel recruitment of TA, Obliques, with abdomen flattening and ribs coming together • NO ABDOMINAL POOCHING • Can feel multifidus recruitment • NO PELVIC ROCKING, Pelvic is neutral • NO OVERUSE of Gluteals, hip adductors, • NO BREATH HOLDING

This patient’s progression

• Belly Breathe • Pelvic Brace • Single leg squats • Neutral spine • TA progression • Multiplanar lunges • Coordinate • Prone glute work • Step up/down diaphragms • Hands and Knees • Dynamic plank • Eccentric PFM • Seated • Balance activities • Pain Education • Sidelying • Walking (aerobic • Standing weight shift exercise) and single leg stance

Take Away

• Take time to consider pelvic floor • Take time to understand and make sure your patient understands the combined muscle effort of the Pelvic Girdle • Don’t progress to dynamic function before they are stable • Refer to Pelvic PT!!

19 4/1/2018

When to refer to pelvic PT?

• Incontinence • • Diastasis Rectus Abdominus • Abdominal or that is not resolving with traditional approach • Painful speculum exams, tampon use or intercourse • Bowel dysfunction

Screening questions to identify

• Do you leak urine? • Do you suffer from ? • Do you urinate frequently, > every • Do you leak stool? 2hrs? • Do you have pain in your lower • Do you have pain with tampon abdomen or groin? use, or do you not use them due • Do you have a hesitant urine to pain or difficulty inserting? stream, or unable to start the • Do you have pain with sexual stream? intercourse, or avoid it due to • Do you feel heaviness in your pain? pelvis or feel something “falling • Do you have pain in your out” vaginal/scrotal or rectal area?

references

• Akuthota V, Ferreiro A, Moore T, Fredericson M. Core stability exercise principles. Curr Sports Med Rep. 2008;7(1):39-44. • Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil. 2004;85(3)(suppl 1):S86-S92. • Barton, A. Serao, C., Thompson, J., Briffa, K. Transabdominal Ultrasound to assess pelvic floor muscle performance during abdominal curl in exercising women. Int. Urogynecol J (2015) 26: 1789-1795 • Beales, Darren John, et al. “Motor Control Patterns During an Active Straight Leg Raise in Chronic Pelvic Girdle Pain Subjects.” Spine, vol. 34, no. 9, 2009, pp. 861–870. • Behm DG, Drinkwater EJ, Willardson JM, Cowley PM. The use of instability to train the core musculature. Appl Physiol Nutr Metab. 2010;35(1):91-108. • Bliven, K.H., Barton, A. Core Stability and Injury Prevention. J Sports Health. 2013 5:6, 514-522

20 4/1/2018

references

• Capson AC, Nashed J, McLean L. The role of lumbopelvic posture in pelvic floor muscle activation in continent women. Journal of Electromyography & Kinesiology. February 2011. 12(1):166-177. • Hamner, s. Seth, A. Delp, S. “Muscle contributions to propulsion and support during running.” J of Biomech (2010) 43:2709-2716 • Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. J Spinal Disord. 1998;11(1):46-56. • Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine (Phila Pa 1976). 1996;21:2640-2650. • Hodges, Paul. “Low Back Pain and the Pelvic Floor.” Musculoskeletal Key, 8 Sept. 2016, musculoskeletalkey.com/low-back-pain-and-the-pelvic-floor/. • Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine (Phila Pa 1976). 2003;28:1593-1600.

references

• Leetun DT, Ireland ML, Willson JD, Ballantyne BT, Davis IM. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc. 2004;36:926-934. • Liebenson C. Spinal stabilization training: the transverse abdominus. J Bodywork Move Ther. 1998;2(4):218-223. • Leitner, M. Moser, H, Eichelberger, P et al, “Evaluation of pelvic floor muscle activity during running in continent and incontinent women: an exploratory study” Neurourol Urodyn (2016). • Leitner, M. Moser H., Eichelberger, P. et al., “Evaluation of pelvic floor muscle activity during running in continent and incontinent women: an exploratory study. Neurourol Urodyn. 2017 Aug; 36(6):1570-1576. • McGill SM, Karpowicz A. Exercises for spine stabilization: motion/motor patterns, stability progressions, and clinical technique. Arch Phys Med Rehabil. 2009;90(1):118-126. • Marques, A. Stothers, L. et al. “The status of pelvic floor muscle training for women.” Can Urol Assoc. J (2010) 4(6): 419-424

references

• Moser H., Leitner M., Eichelberger P., Kuhn A., Baeyens J., Radlinger L.. “Pelvic floor muscle activity during jumps in continent and incontinent women: an exploratory study”. Arch Gynecol Obstet. 2018 Mar 10 • Nadler SF, Malanga GA, Bartoli LA, Feinberg JH, Prybicien M, Deprince M. Hip muscle imbalance and low back pain in athletes: influence of core strengthening. Med Sci Sports Exerc. 2002;34(1):9-16. • Sjodahl, Jenny, et al. “Response of the Muscles in the Pelvic Floor and the Lower Lateral Abdominal Wall during the Active Straight Leg Raise in Women with and without Pelvic Girdle Pain: An Experimental Study.” Clinical Biomechanics, vol. 35, 2016, pp. 49–55. • Sjodahl, Jenny, et al. “The Postural Response of the Pelvic Floor Muscles during Limb Movements: A Methodological Electromyography Study in Parous Women without Lumbopelvic Pain.” Clinical Biomechanics, vol. 24, no. 2, 2009, pp. 183–189. • Smith MD, Coppieters MW, Hodges PW, Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurol Urodyn 2007; 26 (3): 377-85 • Tsao H, Druitt TR, Schollum TM, Hodges PW. Motor training of the lumbar paraspinal muscles induces immediate changes in motor coordination in patients with recurrent low back pain. J Pain. 2010;11:1120-1128. • Torstensson, Thomas, et al. “Referred Pain Patterns Provoked on Intra-Pelvic Structures among Women with and without Chronic Pelvic Pain: A Descriptive Study.” Plos One, vol. 10, no. 3, 2015

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