3D Trunk Training for the Female Runner 4/13/2018 MPTA Spring Conference Kansas City 2018

No Disclosures 3D Trunk Training for the Female Runner Missouri Physical Therapy Conference Spring 2018

Jennifer Cumming, PT, MSPT, CLT, WCS Foundational Concepts Specialty Physical Therapy Kansas City, MO

Objectives

1. Understand basic anatomy of pelvic floor bony and soft tissues structures. 2. Understand basic biomechanics of pelvic floor. 3. Understand how pelvic floor activates with running for support of thorax and maintenance of continence. 4. Understand how to coordinate pelvic floor with other supporting muscles of thorax with running

Note fascial envelope formed by obliques and Linea alba anatomy TrA

• TrA fibers form the posterior section of the rectus sheath • TrA pulls across rectus sheath • EO and IO fibers form anterior section of rectus sheath. • Highest compliance of linea alba is longitudinal • Lowest compliance is in transverse plane • Inferior to umbilicus compliance is smaller transversely compared to oblique direction

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Prevalence of DRA

• 100% of women have DRA of 2.7 cm during 3rd trimester Mota 2014 • Many DRA do not close at 8 weeks and remain unchanged at 1 year post-partum Coldron et al 2008, Liaw et al 2011 • DRA can change up to 4 months after discontinuation of breastfeeding • 66% of women with DRA have pelvic floor dysfunction (UI, POP, pain) Spitznagle et al 2007 • Some women have diastasis of other fascial planes as well

Correlation of width and load transfer failure Diaphragmatic assistance with trunk control

• Some women with DRA are able to produce enough force closure of • Contributes to trunk control lumbar and pelvis to have functional load transference with DRA • Resting tone increased prior to peripheral movements • Other women with same inter-recti distance (IRD) fail to regain • Tonically active with sustained activity ability to transfer forces for lumbar and pelvic stability • Modulates activity with respiration during peripheral activities • Factor of difference is not width of linea alba but tension that can be generated across linea alba to left and right recuts abdominus mm • As long as forces are sufficient to stabilize the lumbar, pelvis and thoracic spine, patient demonstrate good load transfer regardless of width of linea alba

Diaphragm attachments Diaphragm

• Xyphoid process • Note how far into the • Internal surfaces of lower 6 ribs thoracic cavity the diaphragm goes. The • Lumbar spine core really starts in • Arcuate ligament arch over mid-thoracic range psoas and quadratus lumborum and runs to pelvic floor.

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Coordination of diaphragm and TrA Diaphragm restrictions

• TrA and diaphragm activity linked with opposing patterns • Hypertonicity of EO, IO, RA or ES often restrict movement of lower • TrA activity increases with expiration while diaphragm activity ribs and prevent proper diaphragmatic excursion decreases • Minimal expansion of rib cage will occur during inspiration with EO, • TrA activity decreases with inspiration while diaphragm activity IO, RA or ES hypertonicity increases • With decreased diaphragmatic excursion, inspiration will occur primarily in upper anterior chest

Bony Structures of Pelvic Girdle Stability of the SIJ

• Innominates • Force Closure • Achieved through neuromuscular • Lumbar spine control • Sacrum • TrA, Multifidus, pelvic floor and diaphragm • Coccyx • Anticipates movement • Hip joints • Single leg stance, ASLR good ways to test this • Form Closure • Achieved through wedge shape/design of joint and weight bearing forces

Sacro-iliac joint function • Absorb vertical forces from the spine and transmit them to the pelvis and lower extremities

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Sacrotuberous ligament Long dorsal ligament

• Runs from ILA to ischial tuberosity. • Runs in mediolateral direction off of PSIS • Increases in tension with sacral nutation • Increases in tension with sacral counternutation • Ligament is an extension of hamstring tendon • Can be a pain generator

Symphysis Pubis joint

Sacrospinous • Cartilaginous ligament joint • Moves very • Ligament has sensory little 1-2 mm fibers and be source of pain after vaginal • Can move in prolapse repairs relationship to • Originates at ILA of the sacroiliac sacrum and inserts joint onto ischial spine

What is the Pelvic Pelvic Floor Muscles (PFM)1 Floor? Layer 1: • Group of muscles at the Bulbocavernosus, base of the pelvis Ischiocavernosus, superficial • Works alongside the transverse perineal abdominal and spinal Layer 2: muscles Deep transverse perineal, urethral sphincter, compressor • Coordinates with the urethrae diaphragm to control intra- abdominal pressure Layer 3: Levator ani (Iliococcygeus, puborectalis, pubococcygeus), coccygeus, Obturator internus

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Pelvic Floor Pelvic Floor Superficial Levator ani group layers • Share common attachments at • Share tendinous attachments with obturator perineal body internus via the arcus tendinous of levator ani (ATLA) • Attach at coccyx, ilium, ischium and pubis • This structural support is important for the stability of the ilium, sacrum and coccyx in relationship to the pelvic floor • Abdominal pressure is transmitted to the urethra via attachment of fascia that is laterally subvesicular to ATLA and PFM, thus impacting continence

Role of Obturator Internus in PFM support • Synergist: PFM, abdominal wall, and hips • Increased activity with running • Synergistic activation of PFM may help to tense pelvic fascial layers • With connection to levator ani muscle the obturator internus (OI) contracts to assist in lifting the PFM • Plays important role in pelvic organ support • Tendons of piriformis and obturator internus join to form a conjoint tendon before inserting on to the proximal femur and hip capsule • Dias, et al. 2017, Leitner et al. 2017, Solomon 2010

Role of facial layers in continence

• DeLancey Hammock theory: increased intra-abdominal pressure positively affects urethral closure pressure and contributes to continence • Initial phase of increased intravaginal pressure during abdominal contraction is caused by pelvic floor muscle activation • Abdominal pressure is transmitted to the urethra through lateral subvesicular attachment to ATLA and PFM • Endopelvic fascial tissue structure stiffens during the reflex contraction of the PFM and forms a supportive layer against which the urethra is compressed. • Leitner et al. 2017

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Fascial tissue for pelvic support

• DeLancey levels of vaginal support: • Level 1: Uterosacral/cardinal ligament • Vertical fibers of paracolpium are continuation of ligaments and insert into vagina and cervix • Loss of Level 1 support contributes to apical prolapse Ship model of • Level 2: Paravaginal attachments along length of vagina • Attach to superior fascia of levator ani mm and ATLA pelvic support • Loss of Level 2 support contributes to anterior prolapse. • Level 3: Perineal body, perineal membrane, and superficial and deep perineal muscles • Support distal 1/3 of vagina • Anteriorly, loss of level 3 support contributes to urethral hypermobility • Posteriorly, loss of level 3 support contributes to posterior wall prolapse or perineal descent

Diaphragm to psoas to obturator internus to Physiology of the pelvic floor levator ani fascial plane • Fascial plane and muscle fiber • Muscle fibers are intertwined and act as a functional unit interdigitation between • At rest the pelvic floor has an active resting tone to maintain diaphragm and iliopsoas into continence obturator internus and into levator ani musculature • Pelvic floor muscles (PFM): are made up of 70% slow twitch, and 30% fast twitch • Slow twitch muscle fibers maintain base tone while fast twitch fibers are recruited for rapid contractions • Lee, D 2016, Padoa, A, 2016

Functions of the Pelvic Pelvic floor function in breathing Floor Inhale: • Supportive: helps to support organs and • Diaphragm actively contracts, and pulls forms the bottom of the “core” down, expanding rib cage and abdomen • Sphincteric: controls openings of • Pelvic floor eccentrically lengthens urethra, rectum and vagina Exhale: • Sexual: orgasm, arousal and relaxation • Diaphragm relaxes up, rib cage contracts, • Stability: assists in stability of sacroiliac abdominals contract joint, pubic symphysis, lumbosacral, and • Pelvic floor contracts and lifts hip joints burrelleducation.com **It is important to note that while this an • Sump-pump: venous, lymphatic pump important concept to understand the pelvic • Herman and Wallace PF1 floor can be trained and needs to be trained during inhale and exhale

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Incidence of Stress Urinary Incontinence (SUI) Biomechanics of pelvic floor muscles in female athletes • Contraction • Elongation • Many women limit themselves from running due to SUI • Closes vaginal, urethral and anal • Opens vagina, urethral and anal openings openings • Prevalence: 41% in female elite athletes • Creates a lift of the perineum • Perineum descends • Highest prevalence is found in sports involving high impact • Ischial tuberosities move • Pelvis opens with widening of together ischial tuberosities activities • Pubis and coccyx come toward • Coccyx and pubis move away • Ground reaction forces between 1.6 and 2.5 times bodyweight each other from each other have been found in running at moderate speed • Voluntary contraction of PFM • Lengthening of pelvic floor causes elevation of PFM and musculature eccentrically • Assumed that those forces are also transmitted to the pelvic floor abdominal viscera • Leitner et al. 2017, Moser et al. 2017

PFM and Central Nervous System (CNS) role Timing of pelvic floor and running in trunk support • In incontinent women, the delay between heel strike and contraction • Pelvic floor and transverse abdominus respond in a feedforward of the PFM is prolonged manner via CNS according to the reactive forces of trunk and • Continent women have greater upward displacement of PFM and increasing intra-abdominal pressure viscera with elevation • Gradual adaptation of PFM is an important factor in continence • Increases of PFM activity with higher speed can be explained by rising meaning as we have increased level of activity we have increased ground reaction forces and associated higher force demands for the PFM and abdominal activation PFMs • Luginbuehl et al 2016, Leitner et al 2017

• Moser et al 2017

Gradual adaptation of PFM PFM reflex activity with running • There is no significant change in PFM response during different intensities in women with SUI • Reflex activity suggests stretch-shortening cycle which consists of pre- activity, eccentric lengthening, and concentric contraction • Gradual adaptation of PFM is an important factor in maintaining continence • Eccentric lengthening is reactive and a stronger contraction can follow which allows for increased muscle strength in a shorter period of time • This gradual adaptation also evident with different running • Clinically, important to train not only PFM activation but also speeds (increased running speeds= increased PF elongation for improved eccentric muscle control pending patient adaptation) findings • Luginbuehl et al. 2016, Leitner et al. 2017, Dias et al. 2017 • Luginbuehl et al. 2016

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Electromyography (EMG) with eccentric vs Normal PFM patterns on EMG with vaginal concentric muscle activation sensor • Muscles must be electrically active during elongation • Voluntary concentric PFM contraction causes cranial or stretch of the muscle displacement and backward rotation of the sensor • Eccentric muscle actions produce less EMG activation • Backward rotation interpreted as compression of vs concentric muscle contractions the bladder against the PFM and vaginal wall • Luginbuehl et al. 2016 • Eccentric PFM contractions causes caudal displacement and forward rotation of the probe • Leitner et al. 2017

Assessment of PFM with vaginal sensor EMG Assessment of PFM with vaginal sensor EMG prior to heel strike at heel strike • In preparation of heel strike, eccentric muscle • Upon heel strike, voluntary concentric muscle contractions causes activation cause caudal translation and forward cranial translation and backward rotation showing lift of levator ani rotation accompanied with increased muscle activity muscles and compression of urethra on EMG • Heel strike terminated the caudal displacement of PFM • Heel strike initiated a quick concentric contraction • Pre-activity prior to heel strike prepares the tendon- • Maximum backward rotation occurs between 71-114 ms after heel muscle system for the absorption of impact forces strike • Eccentric phase is not triggered by heel strike but • No difference between continent and incontinent women with PFM precedes it displacement and rotation • Leitner et al. 2017 • Leitner et al. 2017

PFM activation on EMG with running PFM activity in women and SUI • Static standing: 29.6 %EMG • Prior to heel strike: Eccentric lengthen occurs; • PFM can activate to level higher than MVC during impact activities. • Running EMG pre-activity of 72 %EMG at 50 ms prior to heel • PFM can increase to 200%EMG in incontinent women during running. strike during running at 8km/hr • During impact activities, incontinent women had higher PFM activity • After heel strike: concentric contraction occurs than continent women • Increased EMG activity to 124 %EMG within 214 ms • Leitner et al. 2017, Moser et al. 2017 • During running: max PFM activation varied per person and speed • activity varied from 98 to 238%EMG and pre-activity from 72 to 136% EMG

• Luginbuehl et al. 2016, Leitner et al. 2017, Moser et al. 2017

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Timing of abdominal wall and PFM EMG with changes in running speed muscles activation • During impact activities, PFM contract before other trunk muscles in continent women • Values higher with faster running speeds vs slower running speeds. • In incontinent women, PFM contract after other trunk muscles • Higher PFM activity with faster running due to reflexive and reactive force generation with running • Time from onset of PFM activity to the onset of intra-abdominal pressure, urethral, and posterior vaginal wall pressure increases • Hypothesize during 11 km/hr speed, a fast monosynaptic reflex contributes to continence. follows the impact of initial contact • Luginbuehl et al 2017 • PFM activation and increased urethral pressure before the increase in intra-abdominal pressure assist in maintaining continence • Leitner et al. 2017, Dias et al. 2017

How do we apply this How do we apply this to our patients? to our patients? Forward flexed posture: • What muscles are • What muscles are weak? weak?

• What muscles are shortened? • What muscles are shortened? • How does this impact the pelvic floor? • How does this impact the pelvic floor?

How do we apply this to our patients? Increased lumbar lordosis

• What muscles are weak? Treatment

• What muscles are shortened?

• How does this impact the pelvic floor?

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Biomechanics Biomechanics single squat leg squat

• Pelvic ring moves as one, in all planes • Pelvic ring symmetrical for weight shift • Ischial tuberosities come away from each and squat other • Core contrast for stability • Pelvic floor is eccentrically loaded as are • Hip ER, QL stance side isotonic glutes, quads, gastroc, soleus • Hip extensors, knee extensors, plantar • Abdominal wall and multifidus contract to flexors eccentrically loaded stabilize • Ankle inverters, everters isotonic • Weight distribution, trunk mechanics, • Trunk mechanics, weight distribution knee and hip

Assessment: Functional Strength PFM assessment • Active Straight Leg Raise (ASLR) • Pt. lies supine and is asked to actively raise one leg and then the other about 1 foot off table. Pt. rates difficulty of each leg, examiner watches for stability through pelvis and spine (Mens • To maximize PFM activation for lift and closure of urethra, the PFM et al) must also be able to eccentrically elongate prior to heel strike • Single leg stance/squat • Important to assess ability to both concentrically and eccentrically • Pt. stands, holding onto a stable object for balance, balances on one leg 5 sec, then the activate PFM for best trunk control with running other. Examiner watches for hip drop indicating gluteal weakness. Also this is used as a pain provocation test for pubic symphysis joint. If pt. can perform this can have them try single • Can assess with EMG or digital vaginal assessment leg squat, watching for hip drop, hip IR, knee pronation, foot pronation, trunk flexion as compensatory movements for gluteal weakness

Strengthening PFM High PFM tone considerations with SUI

• PFM activation with cues to “Bring tailbone to pubic bone” or • Women with SUI have increased PFM activity on EMG. “Visualize stopping passing gas and urine” • PFM hypertonicity may be contributing to SUI • PFM activation should occur in conjunction with transverse • This subset will not respond positively to PFM strengthening abdominus (TrA) for maximum trunk control protocols due to poor ability to elongate and activate PFM • Relaxation or “down training” of PFM using biofeedback or tactile cues • Train PFM and TrA with functional activities for muscle strength and • Contract/relax to fatigue • Diaphragmatic breathing motor control • Trigger point release/Soft tissue mobilization • Postural and body mechanics education • Good referral to PFM PT for further assessment for appropriate treatment

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Treatment Strategies for PFM with Running PFM activation in women with SUI

• Assess PFM on EMG while running for PFM activation prior to heel • Incontinent women have higher PFM activity than continent women strike and with heel strike during impact activities. • Eccentric lengthening is occurring prior to heel strike • Suggests that although women with incontinence may have reduced • Assess trunk muscle activation strategies with running, keeping in muscle mass and maximal ability, the activity of their PFM is greater mind the importance of timing activation of abdominal wall and PFM during postural perturbations • Feed forward system • Leitner et al. 2017, Moser et al. 2017 • Look at ability to activate PFM with different forces to adapt to different levels of abdominal pressure and GRF • Look at running speed!

High PFM tone considerations with SUI Using Running as Treatment

• Women with SUI have increased PFM activity on EMG. • Running should be considered for SUI treatment options to increase • PFM hypertonicity may be contributing to SUI reflex activity of PFM • This subset will not respond positively to PFM strengthening • Training protocols should include involuntary reflexive muscle activity protocols due to poor ability to elongate and activate PFM • Quick changes in direction • Relaxation or “down training” of PFM using biofeedback or tactile cues • Contract/relax to fatigue • Increasing and decreasing running speeds and incline • Diaphragmatic breathing • Jumping and hopping activities • Trigger point release/Soft tissue mobilization • Postural and body mechanics education • Remember to look at the entire system! • Good referral to PFM PT for further assessment for • Moser et al 2017 appropriate treatment

References • Bordoni, B, Zanier, E. “Anatomic connections of the diaphragm: influence of respiration on the body system.” J Multidiscip Healthc. 2013; 6:281-291. • Dias N, Peng Y, Khavari R, Nakib NA, Sweet RM, Timm GW, Erman AG, Boone TB, Zhang Y. Pelvic floor dynamics during high-impact athletic activities: a computational modeling study. Clin Biomech. 2017(41); 20-27. • Faubion SS, Suster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012(2); 187-193. • Lee D. The Pelvic Girdle: An Integration of Clinical Expertise and Research. Churchill Livingstone. 2011 • Luginbuehl H, Naeff R, Zahnd A, Baeyens JP, Kuhn A, Radlinger L. Pelvic floor muscle electromyography during different running speeds: an exploratory and reliability study. Arch Gynecol Obstet. 2016(1);117- 124. • Leitner M, Moser H, Eichelberger P, Kuhn A, Baeyens JP, Radlinger L. Evaluation of pelvic floor kinematics in continent and incontinent women during running: an exploratory study. Neurourology and Urodynamics. 2017; 1-10. • Marques A, Stothers L. The status of the pelvic floor muscle training for women. Can Urol Assoc J.2010: 4(6);419-424. Jennifer Cumming, PT, MSPT, CLT, WCS • Moser H, Leitner M, Baeyens JP, Radlinger L. Pelvic floor muscle activity during impact activities in [email protected] continent and incontinent women: a systematic review. Int Urogynecol J.2017; 1-18. • Padoa A, Rosenbaum T. The overactive pelvic floor. 2016. www.foundationalconcepts.com • Solomon, LB, Lee YC, Allary SA et al. Anatomy of piriformis obturator internus obturator internus, 816-569-2802 obturator externus. J Bone Joint Surg 2010; 92-8; 1317-24.

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