4/16/17 1 an Orthopedic View of a Pelvic Floor Patient

4/16/17

History of Women’s Health Problems: An Orthopedic View

of a • World Health Organization: • Conceptualization of health: considers health to be a state of complete Pelvic Floor Patient physical, mental, and social well-being.

• How does that apply to women? Haven’t women been considered all along? Lila Bartkowski-Abbate, PT, DPT, MS, OCS, WCS, PRPC New Dimensions Physical Therapy 75 Plandome Road 611 Broadway – Suite 503 Manhasset, NY 11030 New York, NY 10023

• Examples of Women’s Health Issues: 1.Reproductive health 2.Gynecologic disorders • US Public Health Service identifies 5 criteria that a disease or condition must meet in order to be a women’s health condition. 3.Eating disorders 4.Osteoporosis 5.Breast cancer / lymphedema • Eg: Pregnancy or Menopause 6.Lung cancer, other gynecologic cancer • Osteoporosis 7.Sports medicine injuries specific to women or that are prevalent in women 8.Chronic pain / fibromyalgia 9.Issues of domestic violence and sexual abuse and torture to women 10.Heart disease

What is the reality of a Women’s Health Recognition in Women’s Health Therapist and who do we treat? • APTA created the Women’s Health Certification Specialty in 2011 (WCS) • Men • In the literature, we are now being addressed as pelvic health therapists • Women • PRPC – Pelvic Health Rehabilitation Practitioner, Certified (Herman & • Children Wallace)

• CAPP - Certificate of Achievement in Pelvic Physical Therapy (APTA)

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Parallels and Differences of What types of dysfunction do we see? Traditional vs. Pelvic PT • Stress Incontinence, Urinary Urge Incontinence, Urinary retention • Understanding of pelvic anatomy • Pre-natal & Post-partum symptoms • Fecal Incontinence & Chronic Constipation • Looking above and below a joint • Abdominal Pain • Pelvic Pain: vaginismus, vulvodynia, post-pelvic fractures, MVA • Relationship of lumbar spine/LE to the pelvis • Coccyx Pain/SIJ Dysfunction • Sexual Dysfunction: erectile dysfunction, penetrative pain, • Muscle dysfunction – muscle problem, just in a different place ejaculation pain, testicular pain • Sitting Pain: Coccyx pain, ischial tuberosity pain • Muscles get too weak = incontinence, or too tight = pain & spasm

Bony Landmarks Modalities 1. Symphysis pubis 4. Pubic rami 2. Ischial tuberosities 5. Sacrotuberous ligament 3. Coccyx • Heat, Ice • Ultrasound • Interferential for pain • TENS for pain • Real-time Ultrasound (RTUS)

Manual Therapy Techniques Neuromuscular Re-education

• Cyriax Cross-Friction Massage • Deep Breathing Exercises • Traditional Massage Technqiues • Connective-Tissue Mobilization vs Skin Rolling • Squat & Drop – muscle release

• External and Internal Work • Retraining muscles for proper coordination • Intra-vaginal • Intra-rectal • Biofeedback training

• RTUS

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Therapeutic Exercise Cycle of the Problem:

• Strengthening Exercises – for those who are weak PELVIC FLOOR COMPONENT • Stretching Exercises – for those who are tight

• Understanding when to do each – takes understanding of condition ORTHOPEDIC COMPONENT

Orthopedic Component Does normalizing • Postural Screen: bony landmarks • Pelvic stability starts at the cranium and ends at the feet create pelvic stability? • How much does forward head, thoracic kyphosis and lumbar lordosis play a role in pelvic stability?

Core Strength How are PTs determining What does that mean for pelvic stability? strength and pelvic stability? What is normal?

• Term of the past??? • Objective measures that we can use: • Palpation of Diastesis Recti – using calipers or RTUS • • Poor coordination One-legged standing test (OLS) • Weakness = Pain • Active straight leg raise (ASLR) • How do our patients view core strength? • addresses core coordination • pelvic floor muscle weakness • gives the therapist a good place to start

3 4/16/17

Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers

• Preactivation of the TrA, Oblique Internus, Multifidus, What is normal arthrokinematics Pubococcygeus and Glut Max induce posterior rotation of the ilium relative to the sacrum & muscle coordination for pelvic • Increases tension on the posterior SI ligaments and posterior thoracolumbar fascia before load transfer stability? onto the supporting leg • Co-activation of the trunk and hip muscles increases spinal stiffness and increases compression and stiffness of the SIJ

Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers Optimal Pelvic Stability

• Posterior rotation of the (ilium) inominate in relation to the sacrum is a position for stability during transfer • Normalized biomechanical movement, along with appropriate muscle load coordination paired with optimal strength create core strength and • Anterior rotation occurred in symptomatic subjects stability. during weight bearing. • Anterior rotation is a non-optimal pattern • Abnormal articular and neuromyofascial function during increased vertical loading through the pelvis.

Evidence of Altered Lumbo-Pelvic Muscle Recruitment Pelvic Floor Muscles & SIJ in the Presence of SIJ Pain

• Subjects with SIJ pain syndrome were different in their activation of the pelvic floor muscles, so: • Delayed onset in patients with SIJ pain: • Internal Oblique A.Is it the joint problem that caused the PFM dysfunction? • Multifidus • Glut max in the supporting leg during hip flexion with SEMG • Alteration in strategy for lumbopelvic stabilization B.Is it the PFM dysfunction that caused a deficit in the force closure mechanism of the SIJ? • Disruption load transference through the pelvis

Avery 2000

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Analyze the findings: Pelvic Joint Control Posteriorly: • Internal Oblique Sacral position stabilized by: • Multifidus Multifidus (to S4) • Glut max in the supporting leg during hip flexion with SEMG Coccygeus (ischiococcygeus)

Anteriorly: • IO firing was poor secondary to rib flare, over-dominant rectus? Pubic symphysis stabilized • Poor multifidi firing pattern secondary to increased lumbar lordosis, by: poor TA strength, lumbar vertebrae positioned into rotations creating Pubococcygeus poor firing patterns? TrA • Glut max – does the patient have normalized hip extension, normal Internal oblique capsular ROM or stiffness into relative anterior translation? Lee 2005

Spinal Segmental Stabilization (Hodges) Posteriorly: Sacral position stabilized by • The orthopedic therapist can • Viewed as the composite function of three systems: • Multifidus (to S4) address >50% of muscle firing patterns • Coccygeus (ischiococcygeus) • Osseo-ligamentous system - provides a passive subsystem • Pelvic health therapist will further look at: • Muscular system - provides an active subsystem Anteriorly: • Coccyx deviations: internal & external • Internal pelvic floor muscle • Neural control system - controls the subsystems Pubic symphysis stabilized by assessment • Pubococcygeus • TrA • Internal oblique

Local Stabilizing System Global Stabilizing System

• Intertransversarii • Interspinals • Longissimus thoracis • Longissimus thoracis • Iliocostalis lumborum • Iliocostalis lumborum • Quadratus (lateral) • Multifidus • includes deep muscles which have • Rectus abdominus • Quadratus (medial) origin or insertion on the lumbar • External oblique vertebrae and the pelvic floor muscles • Transversus abdominus • Internal oblique • Global stabilizing system- large, superficial of the pelvis muscles of the trunk that move the spine • Internal oblique Hodges and transfer the load from the thoracic to • Pelvic floor muscles the pelvis Hodges

5 4/16/17

What is diastesis recti?

Thinning or splitting of the linea alba which is the connective tissue connecting two ends of the rectus abdominus CHECK FOR ABDOMINAL Linea alba 1. Thins FUNCTION 2. Splits

Causation and contributing factors?

1. Abdominal laparoscopic surgery 2. Abdominal full-thickness surgery 3. Umbilical hernia 4. Pregnancy 5. Genetic connective tissue make-up 6. Poor abdominal coordination 7. What is keeping the ends of the rectus apart? Lila Bartkowski-Abbate, Copyright 2017 Lila Bartkowski-Abbate, Copyright 2017

Diastasis Recti Controversy Diastesis Rectus Abdominus (DRA) Prevelance

• 66% of women have a DRA in their third trimester and 53% persist • Measurement by finger widths is unreliable immediately post-partum. • 36% remain AbN widened @ 7 wks (Boissonnault & Blaschat, 1998) • Much of the time it was incorrect when compared to Real-Time Ultrasound (RTUS) measurements • No change at 1 year post-partum (Coldron, et al 2008) • 52% of women with PFD (SUI or POP) have a DRA (Spintznagle ,et al • What’s the best way to measure it in the clinic? Depends upon 2007) your clinic’s goals. Finger-width is easy for the patient to self- Lee, Lecture Discover the Pelvis, 2010 measure. • We take this idea and transfer it to the more global population: why are men and children becoming urinary incontinent and/or have long- lasting low back pain?

6 4/16/17

Linea Alba at Rest

< 45 years old > 45 years old

• Supraumbilical >10 >15 mm mm • Umbilical Ring >27 >27 mm mm

• Subumbilical >9 >14 mm mm

Diastesis = Low back pain & urinary incontinence and abdominal pain?

Diastasis Recti Correction Diastasis Recti Correction • How do we bring the rectus abdominus ends together?

Passive realignment of the muscle, then isolation of Sheet wrapped around the thorax • for approximation of the rectus recruitment abdominus – brings the ends of the rectus closer together • Head lift alone isolates the rectus abdominus Head lift Hold 3-5 seconds • Adding a posterior pelvic tilt increases the SEMG activity 30 reps

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What if the first step doesn’t work?

1. Check lumbar spine bony position 1. Understand lumbar mechanics along What you need to do…. What skill-set you need to have…. with basics of flexion and extension 2. Clear out myofascial restrictions that 1. Check lumbar spine bony position are keeping the ends of the rectus and how to treat each dysfunction 1. Understand lumbar mechanics from coming back together 2. Understanding of the myofascial 2. Clear out myofascial restrictions that along with basics of flexion and clock and clearing out soft-tissue are keeping the ends of the rectus extension and how to treat each 3. Rectus stripping – soft-tissue restrictions from coming back together dysfunction technique 3. Rectus stripping – soft-tissue technique 4. Check rib position and look for rib 3. Look for rib flaring and use of 2. Understanding of the myofascial McConnell taping treatment 4. Check rib position and look for rib clock and clearing out soft-tissue flaring flaring 4. Basic hip mobilizations restrictions 5. What are the obliques doing? 5. What are the obliques doing? 5. Basic movements that create more vs 3. Look for rib flaring and use of 6. Normalize spinal curves less diastesis 6. Normalize spinal curves McConnell taping treatment 7. Normalize hip ROM & strength 7. Normalize hip ROM & strength 4. Basic hip mobilizations 8. Teach functional positions: avoid curl 8. Teach functional positions: avoid curl up and down with transitional up and down with transitional 5. Understanding of basic movements movements: use log rolling movements: use log rolling that create more vs less diastesis

Testing and Assessment (Lee) TESTING for SIJ Stability Integrating Lab & Lecture One-legged Standing Test (OLS) • Clinical evaluation for Hip/Pelvis/SIJ: • Standing • Palpate ilium @ ASIS and hug around entire ilium 1. One-legged standing test (OLS) • Palpate S2 using 2 finger pads of digits 2 & 3 2. ASLR- raising one leg in supine and isolation of TrA, PF, Multifidus • Distance between thumbs should stay the same or get a little smaller 3. Decompression • Ilial anterior rotation – distance is greater • Indicates lack of stability • Have patient contract: • TrA, Pelvic floor, both • Use guide wire imaging

Active Straight Leg Raise (ASLR) ASLR Test

• Proven to be valid, reliable and specific to determine: • Helps clinician determine: • load transfer between the lumbosacral spine and lower extremities. • Can identify and isolate the weakest link. A.Whether it is appropriate to start exercises to increase stability. • TrA • PF • Multifidus B.Whether to start techniques to decrease compression and excessive stability.

Mens, 2006

8 4/16/17

ASLR Test ASLR Test • •Ask patient to alternatively Abnormal strategies cause: actively lift straight leg off •Excessive joint compression table approximately 12” off table. •Loss of mobility •Ask pt if it is more difficult to •Increases in IAP lift one than the other. • •Observe for the following Restriction of ribcage mobility for respiration substitution strategies: •Reduced postural control Abd Wall bulging •Pain Trunk rotation Breath holding •Dysfunction Thoracic spine extension

ASLR Test ASLR Test - Decompression Medial compression

Compression at anterior pelvis at ASIS for Transversus Abdominus Compression at anterior pelvis at pubic symphysis is Anterior Pelvic Floor Compression at posterior pelvis at ischial tuberosities is Posterior Pelvic Floor If none of those work, patient may Compression at posterior pelvis at PSIS is Multifidus be too stable. Compression at combinations simulates multiple muscles Look for easier lifting of leg Decompression: Thoracic erector spinae Anterior/posterior cranial

McConnell Tape for Diastesis Recti

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Abdominal Pain Visceral & Musculoskeletal Causes and Treatment CONTRIBUTION OF THE VISCERA

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When is the abdominal pain occuring? Overview of the Superficial Organs

Related to Food/Ingestion Related to Movement/Locomotion

• During the eating phase? • Standing/walking • Where in the quadrant of the • During the digestion phase? abdomen?

• 1-2 hours after eating? • Do they have a diastesis?

Stomach Large Intestines

• The stomach is a muscular organ located on the left side of the upper abdomen. The stomach receives food from the esophagus.

• As food reaches the end of the esophagus, it enters the stomach through a muscular valve called the lower esophageal sphincter.

1. The large intestine has four Function of the Sigmoid Colon parts: cecum, colon, rectum, and anal canal. 2. Partly digested food moves through the cecum into the colon, where water and some nutrients and electrolytes are removed. 3. The remaining material, solid waste called stool, moves through the colon, is stored in the rectum, and leaves the body through the anal canal and anus.

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When to refer out to a pelvic health therapist? • Abdominal pain related to eating • Abdominal surgical history that seems more complicated than basic scar management can release CONTRIBUTION OF THE • Abdominal pain complicated by gas and bloating • Abdominal pain relating to bowel movements MUSCULOSKELETAL SYSTEM TO THE • Abdominal related to sexual activity CAUSATION OF ABDOMINAL PAIN

• Refer to MD • Red flags: fever, sweats, non-orthopedic nature of their symptoms

Shortened Psoas

• Abdominal posturing shifts the 1. Minimizes the passive internal center of gravity up pumping action to the bowel toward the chest: “forces man to 2. Decreases respiration which swing between hypertension indirectly moves the organs and slackness (inefficiency)”. from a cranial to caudal motion Durkheim, “Hara: The Vital Centre of 3. Decreases normal hip Man” extension which decreases glut strength

Iliopsoas

• Positioned to travel with the • Psoas functions as a counter-balance to the rectus, maintaining a aorta move through the thorax centered anterior-posterior relationship. and are postioned adjacent to • However, all the abdominals muscles are directly balanced by the the ascending and descending length of the hamstring. colon. • The balance between the iliopsoas complex, the abdominals and the • Contraction/relaxation of hamstrings maintain a functional relationship. iliopsoas creates passive bowel • Koch, L. The Psoas Book, 1997. motility.

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How do we retrain the deep core muscles? Psoas Hyperactivity

• 2008. Edelstein J. Rehabilitating Psoas Tendonitis: A Case Report. • Postural re-education HSSJ 2009; 5: 78-92 • Check ribs/check for rib flare • 43 y.o. female referred to PT with dx of bilateral hip labral tears and psoas tendonitis. • Turn off the overactive psoas • Sxs: popping and pain in both hips x 3 years and hx of LBP. • Pilates made her low back pain worse

Psoas Rehab for Hyperactive Psoas • Psoas Inhibition Technique • Facilitation of quadriceps and tibialis anterior • Radiographs detected R-sided anterior acetabular bone spur • Coincident inhibition of the hamstrings and psoas • Trunk curl with only scapular off the mat • Patient went to prior PT for core strengthening and psoas • Prone e-stim on multifidi in prone with ipsilateral psoas with lengthening. knee into pillow when the stim was on • 4 months of PT with symptomatic improvement, but still with • Followed by upright standing and moving into striding with bilateral hip pain cueing • Pilates Reformer with full foot series – engages functional core • Patient sought treatment at HSS control and stability while moving the lower extremities • MRI confirmed bilateral labral tears. • Psoas Bum Walk – promotes isolated psoas strengthening • Standing and walking posture reviewed

An overactive muscle must first be inhibited

Normalizing multifidi firing Psoas Inhibition during ambulation • Facilitate anterior tibialis and • While connected to e-stim to quadruceps facilitate multifidi • • Inhibit hamstring and Have patient push knee into table during contraction to psoas simulate normal multifidi firing • Movement is to dig pattern during ambulation heels into table as to push self up the treatment table

13 4/16/17

Psoas Bum Walk

• Developed by Erl Pettman • Without moving laterally, have patient scoot forward to strength the psoas WHAT IS THE IMPACT OF THE • Patient has to advance forward only using the psoas PELVIC FLOOR MUSCLES? • Alternate R to L buttock

Referred pain patterns of abdominal pain

• Do we think about the pelvic floor muscle group as a co-contributor to abdominal pain? • Is abdominal pain an extension or progression of low back pain? • During your pelvic examination: HOW DO WE TREAT ABDOMINAL • think about is there laxity in the anterior vs. posterior compartment? • Is there overactivity in the anterior vs. posterior compartments? PAIN?

To Decrease Thoracic Kyphosis Check List • Postural Screen – back to the basics • Towel rolls • Are normal spinal curves present? • ½ foam roller • Are the ribs flared? • Full foam roller • Are the rings rotated? • • Does the rectus fire appropriately? Lie supine over Bosu/Ball • Is there diaphragmatic breathing and passive • Medicine ball roll on SP expiration? Lie over roll for 5 minutes in the AM & PM – • Is there true normal hip extension? • Is the psoas overactive and uncoordinated? using the low-load/creep theory • Is iliacus bound down? • Diastesis present? Pectoralis major stretch with every rest room visit

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Lumbar Lordosis Correction Lack of True Hip Extension

• Is it caused by gluteus weakness or tight hip flexors? • Compensations can be seen in many ways • Increased lumbar lordosis: tight psoas, quadriceps • Excessive sacral mobility: is ilium medially/laterally glided? IT DOESN’T REALLY MATTER Iliacus tightness, pubococcygeus tightness? Is there sacral- ilial disassociation? • Increased pelvic torsion during ambulation • Decreased relative hip anterior translation • Intervention will require the correction of both • Knee hyperextension • Medial/Lateral heel whip during FF push off • Obturator internus tight

• Hip Flexor Stretch

• Use Bosu or mat/towel

• Isolation of the gluteus maximus and minimizing lumbar lordosis

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• Orthopedic dysfunction is the major contributing factor to patient’s c/o: • Low back pain: core coordination training needed • Urinary Incontinence: core coordination & pelvic floor muscle training • Abdominal pain: psoas overactivity, organ dysfunction & core coordination

Conclusion • When correction of many of the orthopedic components fail, it is then time to refer to a pelvic floor physical therapist: • Low back pain: core coordination training needed & pelvic floor muscle overactivity • Urinary Incontinence: core coordination & pelvic floor muscle training • Abdominal pain: psoas overactivity, organ dysfunction & core coordination

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How to find a pelvic health therapist?

• www.apta.org • Find a PT • Women’s Health

• www.hermanwallace.org • Practitioner Directory BREAK FOR DELEGATE MEETING

NEXT IS LAB….. • [email protected]