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Influence of Pelvic Floor with Running Combined Sections Meeting 2018

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Influence of Pelvic Floor with Running Combined Sections Meeting 2018 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 Property of J Cumming, PT, MSPT, CLT, WCS. Do no copy without permission 1 3D Trunk Training for the Female Runner 4/13/2018 MPTA Spring Conference Kansas City 2018 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. Property of J Cumming, PT, MSPT, CLT, WCS. Do no copy without permission 2 3D Trunk Training for the Female Runner 4/13/2018 MPTA Spring Conference Kansas City 2018 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 Crossfitforglory.com Property of J Cumming, PT, MSPT, CLT, WCS. Do no copy without permission 3 3D Trunk Training for the Female Runner 4/13/2018 MPTA Spring Conference Kansas City 2018 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 Property of J Cumming, PT, MSPT, CLT, WCS. Do no copy without permission 4 3D Trunk Training for the Female Runner 4/13/2018 MPTA Spring Conference Kansas City 2018 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 Property of J Cumming, PT, MSPT, CLT, WCS. Do no copy without permission 5 3D Trunk Training for the Female Runner 4/13/2018 MPTA Spring Conference Kansas City 2018 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 Property of J Cumming, PT, MSPT, CLT, WCS. Do no copy without permission 6 3D Trunk Training for the Female Runner 4/13/2018 MPTA Spring Conference Kansas City 2018 Incidence of Stress Urinary Incontinence
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