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A Literature Review How the Stability of the Pelvic Floor Complex Affects the Lumbar Spine By: Abigail Scheer Faculty Advisor: D

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A Literature Review How the Stability of the Pelvic Floor Complex Affects the Lumbar Spine By: Abigail Scheer Faculty Advisor: D 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 Scheer, A. Page 2 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: Scheer, A. Page 5 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 Scheer, A. Page 6 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.
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