A Literature Review

How the Stability of the Pelvic Floor Complex Affects the Lumbar Spine

By: Abigail Scheer Faculty Advisor: Dr. Brett Winchester

18 October 2013

ABSTRACT

This literature review explores the connection between the pelvic floor muscle complex and the stability of the lumbo-pelvic region of the spine. The research analyzed depicts the role of the pelvic floor musculature in the function ability of a person’s core, and how acute low back pain can be diminished and controlled, with a reduction in the likelihood of recurring episodes, if proper stabilization exercises and rehabilitation training are instituted. Weakness of the pelvic floor can result from a myriad of triggers, which can be addressed by studying the operation tactics of a person’s underlying muscle groups, and finding the correct method of improving them.

Key Words: pelvic floor muscles, PFM, low back pain, lumbo-pelvic instability, core stability, incontinence

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INTRODUCTION

Pain centered on the lower back is a common phenomenon in the world. It is a condition that appears episodically and with no definite solution in sight. Eventually those thwarted with this ailment surrender to the pain and inconvenience, feeling that even if they win the battle of one flair-up, another incident is just around the corner. Low back pain has become a frequent and costly diagnosis that plagues roughly 38% of the population at some point during a lifetime. It is one of the top injuries to cause professional athletes to be benched during a match. As much as

30% of the professional athletic population has reported holding onto a low back complaint for multiple years.1 This complaint has become so engrained in the norm of everyday culture that a common turn of phrase when a situation goes awry or a person commits an unforgivable faux pas is to relate it to a “pain in the butt (or lumbo-pelvic region).”

While low back pain is such a common diagnosis to be gifted, it is also one of the most mysterious when it comes to solving the case as to what the root cause is. The lumbar spine’s lot in life circulates around stability and mobility. This may appear to be a double edged sword of contradictory parts. However, these roles, while they seem to be polar opposites, are actually interdependent on one another for proper function.

Intrinsic muscle stiffness managed by the neuromuscular system and the proper function ability of the reflex response are key players in modulating the needed joint stiffness to create stability of the lumbar spine and sacroiliac joints.2-4 There are three sub-systems that combine to create the stability needed for proper spine maintenance. Spinal ligaments, vertebral discs, and osseous structures together create the passive sub-system of stability. An active sub-system is designated by the recruitment of muscles, which is responsible for intrinsic muscle stiffness.

Finally, a neural feedback sub-system is comprised of responses that are both reflexive and

Scheer, A. Page 3 voluntary.4 Therefore, proper muscle function and co-contraction is critical for sufficient stiffness to adequately stabilize the spine.

The transversus abdominus and multifidus muscles are the local muscles of the lumbar segments of the spine. These muscles that are deeply rooted to the spine co-activate with the diaphragm and pelvic floor muscles to control spinal stability.5 Deficits in the motor function of these core muscles, which cause a stall in the feed-forward contraction mechanism of the local muscles, have been found to be present in patients suffering from low back pain.5

Core stability is a popular trend in the world of physical fitness. The goal of abdominal muscles that resemble a six pack is at the top of many wish lists. However, the abdominal muscles are but a single component of the human core. Thinking of the core as a box, the top would be the diaphragm, the walls would be the superficial and deep abdominal muscles, and the bottom would be the pelvic floor complex.1 These muscle groups must interact in a synergistic relationship to develop optimal core stabilization, and in turn appropriate balance of the lumbar spine.

For years, studies have been conducted to research the significant role pelvic floor muscles play in the maintenance of continence. However, only in recent years have researchers begun to conduct studies to answer questions regarding the many hats of function the pelvic floor muscle complex wears, and the team members it must interact with to complete its tasks. Proper diaphragmatic breathing and the ability to engage the transversus abdominus and internal obliques all contribute to the feed-forward mechanism of the pelvic floor muscles. The complex of muscles creating the pelvic floor serve as controllers of continence and monitors of intra- abdominal pressure, but growing research and explorations in rehabilitation have determined that

Scheer, A. Page 4 these muscles also stabilize the lumbo-pelvic spine and provide adequate stiffness for the sacroiliac joints when acting in accordance with one another.6

This review of current literature explores in particular the role of pelvic floor musculature in the stability of the lumbar spine. However, in order to accomplish this task, one must also investigate the reliance of the pelvic floor muscles on diaphragmatic breathing and ideal engagement of the superficial and deep abdominal muscles. Through the study of the ideal function of this complex, what can go wrong when weaknesses strike, and how to repair the vulnerabilities that act as both instigators and results of damage, this review will encompass the character of the pelvic floor.

METHODS

The research database available through the Logan College of Chiropractic Learning

Resources Center was employed for this literature review. Specific search engines utilized to find appropriate articles included PubMed and Google Scholar. The search terms included when hunting for suitable sources were as follows: pelvic floor muscles, PFM, low back pain, lumbo- pelvic instability, core stability, and incontinence. This research was collected between the months of March and July in the year of 2013.

DISCUSSION

Pelvic Floor Complex and Respiration:

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An average respiratory rate for an adult is 12 breaths per minute, totaling to roughly

17,000 breaths each day. The seemingly simplistic, yet vital, task of respiration is actually quite complex, requiring the coordination of multiple muscle groups and a well-developed postural structure to accomplish this chore. The act of inhalation causes the diaphragm to move inferiorly, creating a negative pressure zone in the thorax. This, in turn, causes the ribs to rotate externally and the lumbar spine to move anteriorly and superiorly.1

When coordination and structural balance are lacking, suboptimal respiratory patterns result. Air is not drawn in as efficiently under sub-par breathing capabilities and the abdominal muscles are forced into excessive relaxation during inspiration to create the necessary expansion of the thorax. These short-comings result in shallow respiration that is concentrated in the upper chest, rather than the thoraco-abdominal region.1 This less than ideal breathing pattern, if left unchecked for a prolonged period of time, will result in shortening of the diaphragm, hyperinflation of the lungs, and excessive use of accessory respiratory muscles.

Improper respiration and diaphragmatic function is noted with low back pain complaints.

According to research conducted by O’Sullivan et al, individuals with pain in the lower back experience diminished movement of the diaphragm, dropping of the pelvic floor complex, and increased respiratory rate when transferring their load through the lumbo-pelvic region while breathing.7 Therefore, with education of the proper coordinated control of the diaphragm, pelvic floor, and deep abdominal muscles, improvements in respiratory patterns as well as low back pain can be seen.

Pelvic Floor Complex and Transversus Abdominis

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J. A. Hides et al. researched low back pain based on biomechanical instability in cricket players.8 Cricketers with low back pain complaints were found to have a lesser capability to effectively draw in the abdominal wall, a test that is primarily utilized to note the thickness and strength of the transversus abdominis muscle. It was also determined that the anterior abdominal fascia had a diminished amount of slide as compared with that of asymptomatic players.

Asymmetries of quadratus lumborum and internal oblique muscles were seen in symptomatic cricket players as well.

The transversus abdominis muscle contributes to the stabilization of the lumbo-pelvic area by aiding in the creation and harnessing of one’s intra-abdominal pressure. Tensions of fascia are also affected by the transversus abdominis. Those with low back pain complaints tend to have lumbo-pelvic muscles (particularly internal obliques and transversus abdominis) that are over-zealous in contractibility. With stabilization training, a decrease in the amount of contraction of the internal obliques and transversus abdominis muscles was seen during abdominal bracing activities. This, in turn, allows for an increase in the amount of intra- abdominal pressure that can be cultivated by the core musculature.8 Rehabilitation exercises that focus firstly on the individual contraction of the transversus abdominis have been found to be most effective in the beginning prior to the re-instatement of higher load exercises.8 Research shows that the transversus abdominis does create a protective environment for the lumbar spine, solo from the rest of the abdominal muscles.9, 11

The act of “drawing-in” or bracing the abdominal wall will engage the transversus abdominis, along with the superficial abdominal muscles. This can be carried out in a four-point kneeling position. To create a more specific exercise and zero in on the strengthening of the transversus abdominis on a deeper level, one must also focus on the contraction of the pelvic

Scheer, A. Page 7 floor muscles. This alteration to a simple exercise allows for a more selective contraction of deeper abdominal musculature.

The research conducted by Duncan Critchley with the Division of Physiotherapy at

King’s College in London found that the transversus abdominis muscle thickness increased

49.71% with abdominal bracing alone. If the pelvic floor muscles were engaged during this

“drawing-in” movement, the muscle group was found to increase in thickness by 65.81%.9 Those with low back pain have been found to have a decreased thickening of the transversus abdominis during low load isometric activities than those without low back pain.5 This can be attributed to the lack of strength and stability of the pelvic floor muscles, the transversus abdominis’ partner in contraction. Even when particular muscle groups are seen as lone rangers in the face of their function ability and contributions to the overall operations of the core, interactions between sub- groups are still needed for optimal performance.

Role of Pelvic Floor Complex in the Core

The musculoskeletal core is located centrally in the body so as to allow for optimal stabilization of all mechanical segments of the being. Stability is present in the proximal most parts of the body, in order to provide mobility and controlled force to the more distal parts.10

This set-up, known as the kinetic chain, acts much like any well-contrived plan from an athletic team’s play book. For instance, just as a soccer player squares up his torso to create the ideal point of contact and line of drive for a corner kick, the core’s main players of strength, equilibrium, and kinesis allow for optimal placement of the distal segment in order to yield peak results.10

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It is proven that a person’s core must utilize active structures in order to provide proper stiffness and stability for the spine and evade injury.11 Any leakage of energy or control can cause a previously stable system to falter leaving a gap for damage. When heavy loads are quickly taken on hand, the core must be able to contain all energy and divvy it out in the proper biomechanical manner.

Research published in 2004 by Morten Essendrop and Bente Schibye followed men and women working as nurses in Denmark.11 This study focused on the degree of intra-abdominal pressure engaged when one is placed in a position to lift a heavy item in a fast-paced scenario. It was found that when a heavy load, such as a fallen patient, needs to be lifted quickly, the amount of intra-abdominal pressure developed is higher than when lifting a smaller load. Along with this surge in intra-abdominal pressure, comes an increase in extension torque.11

This study went as far as to separate the participants into categories, comparing the capabilities of men versus women. It was found that while both genders increased intra- abdominal pressure and extension torques when met with a heavy-load, men noted a higher rate of intra-abdominal pressure growth. The women in the study were unable to activate their abdominal muscles to the same degree as men during the Valsalva maneuver. It was also determined that due to a woman’s build, which often includes a smaller reach than a man, she must flex forward more than a man in order to reach her load. This decreases the extensor torque in women. It was also hypothesized, that a woman’s pelvic floor musculature may be a limitation to creating intra-abdominal pressure to the same extent as a man. This was found to be the case in women who had birthed children and those who had not.11

Incontinence via Poor Control of the Pelvic Floor Muscles

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Weakness of the pelvic floor complex can be attributed to faulty posture and a loss of neuromuscular control of the core musculature.1 These ailments have been found in those with sacro-iliac joint pain and low back pain. These short-comings, when allowed to endure indefinitely also have oppositional effects on respiration.1 Loss of stability in the pelvic floor reaches beyond the bounds of musculoskeletal aches and alterations. Incontinence, pelvic girdle pain, and prolapse are other known, yet unwelcome, consequences.

Research has proven that the pelvic floor complex is not an independent unit that stands alone and works alone. It teams up with other deep muscle groups to bring stability and coordination of bodily functions. However, this strategically active muscle group is often left forgotten causing vital routines of the body to become uncoordinated and sub-par. A study published in 2012, investigated the relationship between pelvic floor operations and dysfunctional voiding.12 43 patients between the ages of five and 13 years old were selected to participate in this research, and 24 of them experienced urinary incontinence. It was identified that these neurologically normal children had a history of over activating the external urinary sphincter with the goal of blocking the detrusor reflex.12 In other words, they were “trying to hold it” too often. Over time, these behaviors created over activation of the pelvic floor muscles and the abdominal wall that was difficult to relax, yielding non-ideal voiding situations, obstructed defecation, and even pain in the perineal and perianal regions.12

Relaxation for these young people was the key. Diaphragmatic breathing exercises and pelvic floor exercises were introduced into the kids’ daily routines, with the goal of consciously turning on all core muscles and educating the participants on body awareness.12 After one year of these exercises, 20 of the 24 children who entered the study with dysfunctional voiding, no longer had that complaint.12 By properly engaging the abdominal wall and pelvic floor complex,

Scheer, A. Page 10 the children were able to take control of muscle relaxation when it came time to void the bladder.

With balanced and strengthened musculature comes the even more important ability of control.

Pelvic Girdle Pain and its Relationship with the Pelvic Floor Muscles

The human body was designed to operate at an optimal level. Each component of the structure has a purpose and is a vital player in the chain of activity required for maintained conditioning. However, hiccups and alterations to biomechanics create weaknesses, energy leaks, and breaks in the links of performance. Pelvic girdle pain affects 45% of pregnant women and

20-25% of those shortly after giving birth.13 Anatomical structures falling within the normal range of function in the pre-parous woman morph and adapt with the changes that come along with pregnancy. However, there is not a 100% guarantee rate on returns in the post-partum world.

With the progression of trimesters and an ever-growing abdomen, the pregnant female will experience a stretching of the linea alba, or the connective tissue linking the abdominal muscles.13 This stretch will recede in the direction of normalcy in the year following pregnancy.

The excessive residual stretch remaining after that year is known as Postpartum Diastasis Rectus

Abdominis. 66% of the women dealing with this loss of stability have a dysfunctional pelvic floor complex, resulting in urinary incontinence, fecal incontinence, and/ or pelvic organ prolapse.13 Low back pain has been found to go hand in hand with these afore mentioned shortcomings. In Iran, 84% of women who have been pregnant have a lifetime occurrence of low back pain.14

There are two compensation patterns that these women typically use to generate stability.

One approach is affectionately termed the “butt-gripper.” This includes posterior tilting of the

Scheer, A. Page 11 pelvis, and a loss of the lower lumbar lordosis.13 This is accompanied by the inferior compression of the sacroiliac joints. Holding this position for a prolonged period of time creates fatigue and eventually leads to a reduction of the support provided by the pubic bone. As a result of this, the pelvic floor muscle complex becomes more tightly contracted to make up for a loss of support.

The second scheme taken on by women who hope to regain their previous level of stability is “chest-gripping.” To accomplish this approach, superficial muscles are overly utilized and the deeper muscles are left lax and underutilized. In this case, the external oblique muscles are contracted to make up for the lack of activation of the transversus abdominis muscle.13 This increases the pressure in the lower abdomen and also creates a bulging appearance of the lower abdomen, placing higher burdens on the soft tissue and internal organs of that area.

Both of these gripping methods create asymmetries in the muscle complex of the core, ultimately modifying the natural abilities of the pelvic floor complex; however, not for the better.

Even those women, who are able to recover the apparent function ability of their core muscles and recoup their continence capabilities, will become incontinent by five to seven years later in

31% of the cases recorded.13 The lagging revisiting of this condition is attributed to the eventual fatigue of the core muscles and the delayed setting in of the neuromuscular re-education.

The loss of the balance of deep stabilizing muscles is thought to contribute to

lumbo-pelvic instability.6 Pelvic floor muscles aid in the maintenance of intra-abdominal pressure and sacroiliac joint stiffness. An ideally functioning pelvic floor complex lifts the pelvic organs and allows for form closure of the sacroiliac joints. Research shows that women with low back pain complaints often end up lowering the pelvic floor muscles.6 This creates increased vaginal resting pressure and increased activity of the pelvic floor muscles themselves in the hope

Scheer, A. Page 12 of protecting against pelvic girdle pain.6 The coccygeus and levator ani muscles of the pelvic floor complex utilize increased intra-abdominal pressure to resist downward movement of the complex in the ideal situation.15 Increases in intra-abdominal pressure intensify spinal stiffness.15

The over stimulation of the pelvic floor muscles creates counter nutation of the sacroiliac joints, a reduction in force closure, and ultimately, the maintenance of discomfort in those with pelvic girdle pain and low back complaints.6

The active straight leg raise can be utilized to test the load transfer through the pelvis.16 A woman with over contraction of the pelvic floor muscles will have a loss of stability of the pelvic ring, which will reduce the capability of load to transfer through the pelvis. Post-partum women that test positive in the active straight leg raise test have been found to have underperforming diaphragmatic and pelvic floor muscles.17 Altered breathing patterns will be noted in those with a positive active straight leg raise test.18 Manual compression, the utilization of a sacro-iliac support belt or abdominal belt for instance, can help to reverse this muscle re-education as a result of low back pain.17

The pelvic floor muscles are meant to automatically accommodate changes in intra- abdominal pressure, shorten its length, and narrow the levator hiatus.16 Research has shown that the levator hiatus is found to be larger in women who are plagued with urinary incontinence due to the loss of pelvic floor muscle control. In a study pusblished by Eliasson et al. in 2008, it was determined that 78% of women who had low back pain also reported urinary incontinence.14 It is a circle of reactions that are both causes and results of one another. Low back pain causes a woman to over contract muscles in order to compensate for the pain and lack of stability, resulting in overly contracted pelvic floor muscles. In turn, excessively contracting the pelvic

Scheer, A. Page 13 floor muscles will eventually cause fatigue, and the compensations made to the myofascial tissues will egg on the low back pain symptoms.

Relationship between Pelvic Organ Prolapse and Pelvic Floor Muscles

Research has relayed that roughly 50% of post-parous women acquire weakened pelvic floor support, causing varying degrees of pelvic organ prolapse.19 This affliction greatly affects a woman’s lifestyle and is accompanied by symptoms of vaginal bulging and a sense of heaviness.

Braekken et al. reported in research published in 2010 that women suffering from pelvic organ prolapse symptoms make up 20% of the waiting list for those wanting gynecologic surgery.19 Of those women that have a reparative procedure, more than half experience a relapse in symptomatology, and nearly one-third of those women end up having a follow-up procedure.

As it has been illustrated multiple times in this paper, the strength of the pelvic floor complex greatly affects the stability of the lumbar spine, and in turn the reliability of continence.

It is also known that the degree of solidity of the pelvic floor muscles aids in the reduction of prolapse of the pelvic organs. The study conducted by Braekken et al. followed women with varying degrees of prolapse for six months, leading pelvic floor muscle exercises on a regular basis.19 At the end of the six month period, women who participated in the exercise program had an elevation of both the bladder and rectum within the pelvis, as made visible by ultrasound imaging.19 No adverse effects have been found in relation to such exercises, and 56% of the women who had a prolapse below the hymen had successfully decreased their incidence of prolapse by the end of the six month period, according to the research.19

Pelvic Floor Dysfunction in Men

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As noted previously, trauma and a lack of stability and control can greatly alter the abilities of the pelvic floor complex. 80% of women delivering a baby vaginally will experience denervation of the of the pubococcygeus muscle, a key player in the pelvic floor.20 Just as giving birth can disrupt the response required to trigger a contraction of the pelvic floor, so can a traumatic surgery like a prostatectomy. Sapsford’s research states that while the negative effect of a neurological disturbance during a prostatectomy or a vaginal delivery, will settle after just seven days, lasting damage can remain, and rehabilitation will be necessary.20

Pelvic Floor Muscle Activation Depends on Body Position

Today’s society has become very sedentary. While physical activity is worked into the lives of a large percentage of people, a good portion of the day is also spent sitting. People get up in the mornings, sit in the car to drive to the office or school, sit at a desk for work, sit during their lunch break, sit in rush hour traffic on the trek home, sit down at the dinner table for the evening meal, and then maybe they relax and lounge around to catch their favorite sitcom in the living room before bed. The key word in all of these scenarios is “sitting.” Those who wish to lead balanced lives and be physically fit often think about how much they sit throughout the day, but a key point is missed in this line of thinking. An important question that should be addressed, is not only how often one is sitting, rather in what position they are sitting. The study published by Sapsford et al. addresses the different sitting postures one may adapt, and which position tends to provide a greater activation of the pelvic floor complex, and even the abdominal muscles in parous women.21

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Pelvic floor muscle contraction is at its highest in the standing position and at its lowest when lying down. In a world where sitting is a position that rules over a large chunk of a person’s day, how can it be utilized to create the highest possible level of instigation of the pelvic floor? Sapsford and associates found that pelvic floor muscle activity increases the most when sitting in a “tall unsupported” position.21 The pelvic floor complex is often found working with the abdominal muscles, mainly the transversus abdominis. In order to gain maximal activation of the pelvic floor complex, the abdominal muscles must also be turned on. In contrast, a person sitting in an “unsupported slumped” position holds their posture and gains stability mainly from the ligamentous components that surround the spine, rather than the pelvic floor and abdominal muscles.21 The pelvic floor complex can be engaged throughout the day, even while sitting, with the goal of furthering its enduring abilities to hold contracture for prolonged periods of time.

Passive versus Active Stiffness of the Lumbar Spine

As mentioned previously in this review of the literature, a slumped seated posture is maintained primarily by ligamentous structures, rather than muscle contracture. This creates a passive trunk stiffness of the lumbar spine rather than stability set in by active stiffness. Passive trunk stiffness is achieved in a manner that utilizes ligaments, yet lacks the control provided by muscle contraction.3, 22 Therefore, while this type of stiffness may provide a sense of rigidity, it is majorly lacking in the secure nature that comes with trunk stability. Active stiffness is achieved via co-activation of antagonistic and agonistic muscle groups.3 In the region of the lumbar spine, these roles are carried out by the abdominal muscles and extensors, respectively.

The abdominal muscles create a flexion moment arm, while the extensors aid in the extension of the back, balancing out to maintain a neutral spine.3

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This active approach to stability requires the participation of the intrinsic muscle group as well as the reflex response, as mentioned in the introduction of this paper.3 These necessities are lacking in those with low back pain. In order to compensate for these great losses, low back pain sufferers over-recruit antagonist and agonist muscle groups in order to maintain a level of rigidity and make up for the loss of neuromuscular management.3

When looking to regain stiffness in the lumbar spine and relieve the symptoms of low back pain, passive and active care provide different roads to travel. An option chosen by some is the use of an abdominal belt. While some progressive results may be noted after its use, the negatives and shortcomings far outdistance the known positives. There is no doubt about it, the use of an abdominal belt does provide a solid firmness and unyielding rigidity that allows for a sense of relief and a feeling of a strong hold on the lumbar spine in those suffering with low back pain.

However, research has shown that the muscles that are designed to provide that sense of stability, namely the spinal extensors and abdominal muscles, lower activity levels when strapped in by the abdominal belt.23 There is a loss of co-activation of these muscles, and prolonged use of the abdominal belt can cause a deficit in active muscle recruitment for spine stability.23 When the abdominal belt is finally removed, the further instability of the already weak stabilizing muscles can actually increase the risk of additional low back injury. This can be attributed to the sudden loss of artificial stabilization provided by the abdominal belt. An active approach to regaining spinal stability and stiffness in the lumbar spine would include rehabilitation of the core musculature to increase intra-abdominal pressure through functional exercises.23, 24 Sufficient intra-abdominal pressure is the essential component called for when

Scheer, A. Page 17 working to regain stability of the lumbar spine through rehabilitated muscles and retrained biomechanics.25

Gaining Control of the Pelvic Floor

Established weakness and an inability to control the contractions of the pelvic floor muscle complex create the shortcomings of the lumbo-pelvic region of the spine, as relayed throughout this paper. It has also been reported that while passive approaches to care may relieve the symptoms of pain initially, the root of the pain and lack of function ability can only be addressed from an active rehabilitation stand point. Without a functional approach dedicated to the restoration of what is found to be lacking in the performance of the pelvic floor muscle complex and its core teammates, there can be no reduction in the amount of relapse that is otherwise eminent.

The pelvic floor is not a solo operator. It is a part of a team of muscles that come together to comprise the core. Together these muscles aid in proper respiration, the gaining of maximal intra-abdominal pressure, restoration of lumbar stability, the reinstitution of continence, and proper maintenance of internal organ positions. These muscles work together to reach common goals. While they may be able to complete the above tasks with a missing member or even on their own, the results would be sub-par and require compensations that would eventually fatigue and result in further damage.

Just as function ability relies on the participation of all muscle components of the core, so does rehabilitation. Weakness of one muscle group leads to the weakness of all muscle groups.

Where one thrives, all thrive, and where one fails, all fail. There can be no MVP that holds the key to carrying the rest of the team through their routines—at least not for long. Even the best

Scheer, A. Page 18 athletes cannot face off against a slew of opponents without tripping up and wearing out after a time.

Rehabilitation of these muscles also calls for a strategy of where to start and what the goal is at the finish. After all, even professional marathon runners must begin at the starting line in order to be successful with their race. If they jump in at the 14th mile, disqualification is eminent, and they are labeled as a failure. Beginning rehabilitation with the wrong muscle group will only yield the instigation of greater compensations, a worsening of the problem at hand, and a loss in the end.

Breathing is the minimal requirement for life. The ability to function and thrive first depends on this act before anything else. It makes sense then to begin rehabilitation with the education of proper respiration, or diaphragmatic breathing.20 This requires 360 degrees of inflation around the core, as well as minimal elevation of the rib cage, and little movement of the chest with inspiration. All muscle components of the core should be activated during the act of proper diaphragmatic respiration. Without mastering the basics, more complex activities cannot be mastered.

In a patient with low back pain who lacks strength in the pelvic floor, it is also vital to practice and master the endurance of the contractility of the pelvic floor muscles. This can be done though extended muscle holds.20 As mentioned earlier in this paper, “tall upright” sitting is a good position for this exercise.21 Progression can include moving into a standing position or even walking while maintaining contraction of the pelvic floor along with co-contraction of the trasnversus abdominis muscle. Just as coaches have always encouraged their players to practice in order to brush even the possibility of perfection, repetition of these exercises is crucial.

Sapsford et al. deems the need for five repetitions of the exercise at least five times each day a

Scheer, A. Page 19 necessity for success.21 The improvement of endurance in pelvic floor muscle contraction will allow for better coordination of co-contraction of the transversus abdominis muscle with the pelvic floor complex. Once this skill is mastered, strengthening becomes the next step of rehabilitation.

The ability to actively recruit the core muscles in an all-inclusive fashion is beneficial for those dealing with low back pain. By addressing the weaknesses and not just the symptoms of the complaint, a rehabilitation regiment can be set into motion providing all of the ingredients necessary to minimize the re-exacerbation of the pain.

CONCLUSION

The pelvic floor complex is jack of all trades. This muscle group is strategically placed within the body to provide significant contributions to multiple functions of the body. These include proper respiration, continence, maintenance of the proper positions of the organs residing in the pelvis, and the stabilization of the lumbar spine. The last role listed for this muscle group has only hit the scene on the research circuit in recent decades. The components of spinal stabilization are still being researched, and the puzzle pieces are still being put together.

Unknowns and unanswered questions continue to drive the research in this particular topic.

The pelvic floor is also fundamental to the allowance of the transversus abdominis, diaphragm, and internal oblique muscles to reach optimal biomechanical function. While these muscles can carry out their roles in a solitary fashion temporarily, research has illustrated that the end of the road on such a trip will always end at a road block. The muscles that are over activated with the goal of making up for the deficit of an under activated muscle will fatigue, leaving larger follies in its wake.

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Low back pain is one of the most common ailments to strike people in today’s world. It eats up large quantities of personal time, capabilities, and medical budgets. Surgeries are often sought out in the hope of finding a quick fix and a simplified route to get out of pain. However, there are no such things as quick fixes or magic solutions. This paper illustrated that a chunk of people, larger than one would ever wish to admit, continue to relapse into the painful and debilitating situations that led them to surgery in the first place.

Research and growing knowledge to understand the kinetic chain and the biomechanics of the body, have allowed for another option. By understanding the roles played by the anatomy surrounding the lumbar spine, as well as the shortcomings that come along with muscle weakness and lack of coordination, a conservative route of rehabilitation can be presented to the patient as a first step before more extreme measures are taken.

The human body is well-oiled system with the ability to run smoothly with proper functioning biomechanics. As people move from infancy to adulthood, the deep muscles of the body tend to be forgotten due to postural changes and the shifting away from natural biomechanics. Superficial muscles become over active in the hopes of compensating for the stability lost with the weakening of the deep muscles. If people can be re-educated on how to utilize all muscle groups in the way they were meant to, pain and shortcomings like mechanical low back pain would become less of a phenomenon, and more of a rarity. The place to start with this change is the pelvic floor.

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