03/18/2019

Jennifer Stone, PT, DPT, OCS, CAPP certified pelvic floor therapist Clinic Supervisor, Mizzou Therapy Services- Rangeline Program Director, Pelvic Health Certificate, Evidence in Motion

• Explain anatomy and physiology of the entire core and its interrelationship with the rest of the body. • Assess for appropriate motor control of core musculature and identify sources of impairment if they exist. • Name at least 3 options for use of manual therapy to provide a neuromotor “reset” to the core. • Provide at least 3 examples of motor control retraining for patients regardless of impairment, beginning with very basic muscle activation and progressing all the way into motor control for high level athletic activities. • Explain what the concept of “core stability” should look like and how to practically apply during exercise and athletic training.

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Floor to ceiling!

• What do we mean when we talk about the core? • Muscles • Strength? • Anticipatory function? • Do we understand how the core actually works?

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• Neck • Pelvis • Deep neck flexors • Pelvic floor • Trunk • Hip adductors • Rhomboids • Gluteus medius • Lower/middle trapezius • Transverse abdominus • Multifidus • Diaphragm • Obliques • Erector spinae • Lattisimus dorsi (and on…)

• Anticipatory control • Core muscles (all of them) should fire. Every time we do anything. • Example: multiple studies show the pelvic floor fires (under normal circumstances) when you reach to open a door or get something off a shelf • Motor control/coordination • Is strength really all that important in the core? Or is coordination the key? • Endurance • Fast vs. slow twitch fibers • We do have BOTH in our core-which to focus on?

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• History • 1960s-1980s-situp/rectus abdominus city! • 1990s-early 2000s-Paul Hodges early theories on motor control and the role of transverse abdominus plus the development of lumbar CPRs including the stability category-PTs started teaching abdominal hollowing/bracing with TrA and teaching patients to “tuck and hold” to maintain support for lumbar spine • Later 2000s-present-Hodges publishes more papers and states that PTs have taken his theories way further than he ever intended and we start realizing the story may not start and end with TrA. Diane Lee publishes her canister theory. At the same time, therapeutic neuroscience education becomes more popular-some people throw out core training entirely. • Short answer: it’s complicated and we may not have all the answers-and this is JUST for the lower core!!

• Dynamic mobile system which must all work together in order to provide ideal structure/function for spine and appendicular skeleton during movement • Balloon example • The key here is intra-abdominal pressure, NOT muscles holding the skeleton still as we once thought • This means that retraining the core WHILE MOVING is much more important than we ever considered; does this mean we throw out TrA activation isometrics entirely? • Motor control AND anticipatory training AND working with dynamic control for “big movements” have to be part of our core work for maximal function • Note role of posture/alignment

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• Let’s chat about the role of each of the major areas of the core in function…as with any good tour, we can start in the basement…

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• 3 layers of musculature-for purposes of this course we are most concerned with deepest layer (stability layer) • Coordinates with diaphragm, transverse abdominus, and multifidus for stability-is it possible to adequately retrain the core while ignoring the pelvic floor? • Connections to pubic symphisis, coccyx, anterior sacrum, lumbar spine, hips

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• Anyone with a postural issue • Patients with current or history of low back pain, SIJ pain, or hip pain • Patients with a history of surgery in one of the above areas or abdominal surgery • History of a difficult vaginal birth or Caesarean birth • Athletes, especially in high impact sports • Postmenopausal women, women who have had at least 1 child • Men • Patients with a history of cancer treated by chemo or radiation • And the list goes on…

• I have more pain during my period. • I have pain with intercourse. • I have trouble with constipation or have a hard time initiating the flow of urine. • I feel pressure/heaviness low in my pelvis. • I have tailbone pain. • I have an SI joint that keeps “going out.” • I have problems with leakage of urine or stool. • I have abdominal pain and cramping that doesn’t test positive for anything else. • I have back pain and have had physical therapy many times in the past and it always comes back a few months after stopping therapy.

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• Piriformis • Tends to be overactive to compensate for underactive PF • Gluteus Maximus • “Butt clenchers”-this is a motor pattern to compensate for a weak core! • Gluteus Medius • The “poles” of the hammock • Hip flexors • More of a mover, but also tends to spasm to compensate for underactive/poor motor controlled core • Hip adductors • Tends to mirror pelvic floor activity

• History of hip pain or surgery • History of low back pain (especially chronic) • History of pelvic girdle pain (especially posterior pelvic girdle) • History of significant change in weight • History of abdominal surgery • History of a limb dysfunction/surgery that caused the patient to limp (or patient was using crutches or a scooter) • Note: We should be working to PREVENT this during rehab for these conditions!!!

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• Transverse Abdominus • The “marathon runner” and deepest muscle • Keep in mind ALL attachments! • Obliques • Rotational support and heavy lifting • Rectus Abdominus • Trunk tilting and heavy lifting

• Multifidus • Erector Spinae • Quadratus Lumborum • Latissimus Dorsi • All of these will often become overly active/spasm to compensate for a weak core-the patients with “steel rods” down their backs as they hang on their ligaments

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• Serratus Anterior • Diaphragm • Roof of lower core/vital role in maintenance of appropriate IAP • What has to happen for diaphragm to work?

• History of abdominal surgery • History of low back pain • History of hip pain or surgery • Reactive response to anything that decreases function in the pelvic floor or hip stabilizer muscles • Runners who don’t also weight train/strengthen • Patients with history of non contact ACL injuries (cause?)

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• Lower Trapezius • Middle Trapezius • Rhomboids • Multifidus • Erector Spinae • Serratus Anterior

• Deep neck flexors • Suboccipitals • IN BALANCE WITH heavy lifters…

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• History of neck pain or surgery • History of thoracic or rib dysfunction • History of shoulder surgery • History of whiplash related injury (even if long ago/mild/didn’t seek care) • And all of the previously mentioned patient types…

• “The Core” is a very complex and dynamic system with a LOT of moving parts and pieces; they ALL have to work well together for the body to have optimal support and function • You really can’t JUST work with 1 of the muscles or even 1 category of muscles if you want patients to have optimal outcomes

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How do I assess the function of the core??

• Manual muscle testing? • Functional movement assessment? • A combination of all of the above?

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• Be sure to ask about: • History of prior injuries • History of falls, motor vehicle accidents, prior surgeries (even years ago) • Birth history (if applicable) • Is pain better or worse with movements? Which ones? • Currently having problems with: • Leakage of urine or stool • Painful intercourse • Constipation

• When core control is happening correctly (in absence of other injuries/issues) you should see good pelvic stability during gait and single leg stance; the person should appear relaxed/not overly stiff and have good trunk movement (regardless of pace) • What might these gait patterns suggest about core control?

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• Symmetry? • Uneven creases? • Significant difference in shoulder height? • Lateral shift? • Posture • BREATHING

• Appropriate posture facilitates ideal core motor control • BUT!! Remember that, via the IAP system, we really should be able to exhibit core support/motor control in a multitude of positions • Posture is probably more of a sign/symptom of lack of core control vs. a position to retrain in therapy (aka: if you fix the underlying issue, the posture likely will improve without you doing much)

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• Improper breathing patterns=most likely inappropriate pelvic floor & core activation patterns • Chest breathing (rising up or flaring out), shallow breathing, creases in back • Overusing accessory muscles • Chest flares or “sucking in” around ribs without excursion of lower ribs • Breath holding

• Look in different positions • Watch throughout treatment-this is a really great clue as to when they are starting to substitute/losing form (breath holding is a huge clue-it’s a way to “cheat” and force IAP without using all their muscles in an organized/coordinated fashion) • If you can get the breathing down, you can use it to help re- teach the rest of the core muscles to work correctly • Palpate the diaphragm and lower ribs to ensure they are moving correctly

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• Request an isolated activation (just PF, just anterior core) and observe what happens with the rest of the core • Warning/trouble signs could include: • Breath holding or large change in the way breath is happening • “Bulging out” of other core muscles • Shaking/jerking of muscles (prior to the point of muscle fatigue) • Lack of coordination for the movement • Loss of balance • Severe tucking of pelvis or “sucking in” of muscles in an exaggerated way • Odd movements of the neck or upper extremities (shoulder shrugging) • Scapular dyskinesia

• Gives good clues about core recruitment and closure across pelvis • Patient in supine, legs extended • Patient lifts leg straight up one at a time 6-12 inches • Ask if one feels heavier/harder to lift than the other, • If yes, patient repeats while therapist applies pressure: • ASIS toward one another (replicates anterior force closure) • PSIS toward one another (increases force closure posteriorly of the SIJ) • Oblique (one anterior / one posterior) • Does it feel lighter/easier compared to previously?

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• Assess for tone & function • Knees supported • Fingers on ischial tuberosity, “sink in” to palpate • Bilateral • Pain, trigger points, resting tone • Palpate hip adductors also-mirror PF activity • Can be performed in supine or sidelying

• Palpate pelvic floor with 1 hand, TrA with the other • Ask patient to contract their abdominal muscles, then ask them to do whatever they think a Kegel is (if they don’t know, ask them to act like they are trying not to pass gas in a crowded elevator) • Assess for ability to contract AND Look to see whether the bottom pulls ability to relax after (KEY) up and in toward the scapula or • Grade: strong, good, weak whether it bulges down toward you. The gluteal muscles should NOT be • Co-contraction with Transverse Abdominus? contracting. What happens with breathing? • Can they? What happens without cuing? Re-teach PF contraction first, then TrA • How long can they hold? • Normal: 10 repetitions at least 10 seconds with good form (is this normal?)

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• Patient in sitting, sidelying, standing • Place proximal portion of hand on sacrum with 2nd and 4th digits on gluteal muscles and 3rd digit on coccyx • Request a contraction of pelvic floor • Inward displacement of coccyx=correct contraction • Outward displacement of coccyx=straining/bulging/ incorrect contraction • No displacement of coccyx=nothing

• Diastasis rectus evaluation • Patient in hooklying • Fingers perpendicular with rectus abdominus, have patient lift head and shoulders up off table • Measured by number of fingers that “sink into” cavity (Width) and depth (Min, Mod, Deep) • Have patient repeat the test and cue breath / Pelvic Floor, does width/depth change? • MOTOR CONTROL/intra-abdominal pressure!

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• Abdominal scar tissue has potential for major impact on pelvic floor & abdominal organs! • Assess structures involved, amount of restriction, tenderness of structures • Difference between a scar and adhesions • Adhesions form as a response to trauma (surgical or impact or emotional!) AND inflammation (endometriosis, pelvic inflammatory disease, gallbladder disease, appendix disease…) • Layers (sink down through each to appreciate where the adhesion is): • Skin • Muscle • Fascia • Organs

• Visual-is it indented? What happens in weightbearing? What changes with breathing? How about functional movements? • Tenderness-or numbness • Gentle, full hand mobilizations in all 3 planes (A-P, rotational, up/down)-where do you feel resistance at various levels? • Symmetry, resistance, pain, guarding, breath changes

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• Watch people move (core predominant work or just typical movement patterns)-what substitution patterns do you see and where? • Movement ideas: • Single leg stance • Tall tandem kneeling • “Bird dog” • Burpee • Pilates roll up or V up • Squat • Step up • Balance on unstable surface • Various types of planks with reaching/slapping/leg lifts

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• Remember that the body does an amazing job of substituting to allow us to continue functioning even in absence of perfect musculoskeletal control/activity • What we lose first is MOTOR CONTROL • Think of the visual things you see as being the clue to what is occurring vs the actual problem (correcting posture without addressing the motor control and the muscles does nothing but give your patient another incorrect movement pattern) • If you lay the right foundation, the higher level activities will fall into place easily • The core has to work more if you are slightly less balanced

How to use manual therapy techniques to facilitate motor control retraining

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• What does manual therapy actually do? • We used to think we were moving joints and stretching tissue-is this accurate? • Most of the recent studies are pointing to manual therapy being a very powerful tool to alter neuromotor input to generate an altered output • Serves as the “CTRL+ALT+DELETE” for our nervous system which allows us to do a more effective “software reboot” (core/motor control retraining/relearning)

• How it should work: • I want to do something • I need to fire all these muscles to make that happen • I fire all the muscles and it happens • I get the positive feedback loop of success • Redundancy • When we repeatedly do an action or activity, our brain starts to “automate” that (you don’t have to think through details of how to turn your car on or brush your teeth

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• Our brain and body do an amazing job of adjusting for non- ideal movement patterns to allow us to keep moving • This is GOOD-how awful would it be if we stopped functioning every time our back was a little stiff? • HOWEVER, if we are guarding an area for a long period of time (pain, surgery, a traumatic incident to the area) the brain can get confused and replace the normal motor pattern with the “protective” motor pattern • If we can “reset” the system, we will be much more successful in quickly reminding people’s bodies of the normal/good motor pattern

• Anything that alters the neural input in the area • Suggest using manual therapy first followed by exercise if your goal is rebooting • High velocity low amplitude thrust (manipulation) • Soft tissue mobilization • Muscle energy techniques • Joint mobilization doesn’t seem to be as effective for this but can still be part of your overall plan of care • Joint mobilization is shown to be more effective for increasing range of motion-especially helpful around rib cage if you think that actual lack of mobility is the issue

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• Goal: facilitate a “quick stretch” or “muscle overload” to help interrupt chronic motor patterns in an area • Does the technique matter? • Decrease in pain, “wipe the slate blank” in order to allow us to build “from the ground up” • Suggested options • Lumbar spine, hips, or pelvis can assist with lower core reset • Thoracic spine can assist with sympathetic chain ganglion reset, bladder issues, postural issues, rib cage excursion, and upper core issues

• Overactive muscles/guarding, especially in posterior chain and pelvic floor • Don’t forget about potential for cervical soft tissue mobilization to help with diaphragm issues • You can also mobilize the diaphragm specifically (incorporate breathing for more of a muscle energy technique • Lower rib cage mobilization can be helpful if rib tightness is preventing appropriate diaphragmatic excursion (especially likely in the lower rib cage)

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• “Reset” pelvis and pelvic floor • Patient in supine, bend into a “C” shape, then rotate (don’t lose the sidebend!), take out the slack, and manipulate

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• Patient in sidelying, bend top knee up to decrease motion in pelvis • Pull bottom elbow down/up (J Stroke) toward ceiling • Tummy to tummy, take out slack, can manipulate, mobilize, MET • This can also be a gentle way to initiate lumbar/pelvic mobility for patients who do not tolerate the lumbopelvic manipulation

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• Pelvic shotgun technique • Patient in hooklying, have them abduct against you 3x8 sec hold, then adduct against fist or forearm, with or without bridge

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• Patient in Thomas/Gaenslen position • Therapist places patient’s foot against therapist’s shoulder, holds opposite leg down • Patient presses (cue hamstrings/press with heels) against therapist for 8-10 second holds, repeat

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• Sidelying sacral distraction • Patient in sidelying, “fetal position” • Therapist provides distraction to sacrum

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• Hip long axis distraction • Patient with 1 knee bent, 1 knee (mobilized side) straight • Therapist grasps around ankles or calves (or can have knee bent and hold under knee) • Hip in open pack position (30/30/30 flx/abd/ER • Can hold or oscillate

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• Hip lateral distraction • Patient in hooklying (can be reclined) • Belt around patient’s leg and therapist • Lateral distraction with varying angles

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• Patient in seated position • Patient slumps, as he/she sits back up, therapist presses down on sacrum • Can be straight line or with a rotational force

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• Over posterior pelvic ligaments/muscles • Supine or sidelying • TFL, piriformis, QL

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• Abdomen • Pelvic floor, obturator internus • Sink your fingers just interior to the ischial tuberosities for pelvic floor, angle toward ASIS for obturator internus • Check for spasm, trigger points, soft tissue mobilization • Supine and sidelying • Use of hip rotation with deep pressure • Contract-relax techniques

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What does “core control” look like?

• We are retraining MOTOR CONTROL, not strength • If the muscles are individually strong, that does you absolutely no good if they are not working together to generate appropriate IAP • Patients WILL feel better if you strengthen individual muscles (some support is better than none) but if you stop here, you risk just giving them another dysfunctional movement pattern (frequent flyers/will be back for their back pain in a few months or a year)

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• Breath retraining-teaching people to breathe into their pelvis/through their diaphragm (this is surprisingly hard sometimes!) • If you can lay this foundation correctly, it will be extremely helpful through the rest of the process • Biofeedback techniques • Remember that appropriate rib and diaphragm mobility are key to being able to achieve this!

• Importance • Diaphragm lowers with inhalation (abdomen rises/expands, PFM descends • Diaphragm rises with exhalation (abdomen lowers, internal organs rise 1- 3 cm, PFM lift) • Evaluation – one hand on upper chest, one on abdomen • Abdomen should rise/fall, also lateral chest expansion – look at symmetry vs. holding patterns or restriction on one side • Retraining/facilitation techniques • “Breathe into my hands” • Therapist using hands to facilitate diaphragm stretch and/or rib excursion

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• “Wing arm” • Sidebend plus breathe

• DO NOT initiate if patient is unable to relax PF! • Start in hooklying or sidelying • Looking for an “up and in” motion with NO pelvic tilting, gluteal activation, or “bulging out” of the abdominal muscles • Hip adductors are facilitory (don’t want to be dependent on these long term) • BREATHING (exhalation) to facilitate PF activation • Verbal cues (different ones work better for different people) • Act as if you are trying to stop the flow of urine* • Act as if you are trying to stop yourself from passing gas • Draw your muscles up and in • (Men) Raise your testicles • Kidney bean lift

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• Should we use them or not? • Is there benefit to learning to isolate a muscle-FOR THE PURPOSE of neuromuscular re-education and reminding the brain where the muscle is/how it works? • BUT should we stay there? For how long?

• Should see a drawing up/in AND ability to bulge down/out (elevator analogy) • Verbal cues (in addition to the previous ones) • Press down like you are trying to have a bowel movement or pass gas • Relax down-go up and in, then back to “rest” then bulge down towards your feet • Pelvic Elevator – going to the basement

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• Start with TrA, then add others • Verbal cuing-try to pull ASIS toward one another • Limit “bracing” strategies – incorporate breath to minimize increases in IAP • Making sure there is a co-contraction with PFM and TrA, then moving into using these (with breathing!) for movement • Unweighting techniques • “Move it and move on,” pelvic floor style

• It’s not enough to teach isolated contraction only • How do we retrain functional movement? • Anticipatory control • Incorporating balance • Sidelying may be a good place to start • Progress into quadruped, then other positions • Can unload a movement, then gravity remove, then add in gravity and resistance • THINK MOVEMENT!!

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• Weight shifts to bias aspects of PF that might need a little more help • Forceful exhale/”blow before you go” • Impact progression using ball • Spread the load/hold (for heavy lift) • (Valsalva up instead of down) • Fill your belt

• Breath retraining-supine, sitting, standing • Pelvic floor contraction addition • Transverse Abdominus • Now incorporate into the following dynamic movements (practice this both as the patient and therapist-how can you cue away from substitution patterns??) • Segmental bridge, segmental bridge with arm movements plus band • Bridge with leg extensions, bridge with hip abduction/adduction • Bird dog with band • Squat (wide, narrow, plie), squat with jump • Plank, plank with reach, plank with leg lift, open hip down dog to plank and back, plank to side plank

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• Also important to incorporate in with breath! • Here, the “foundation” is the scapular stability • Start by teaching a retraction, then add in movement • Exhale on the concentric effort, inhale on eccentric • Movements to add in once you have the basics • Wall angel • B shoulder ER with band and squeeze • Unilateral and bilateral T and Y

• Deep Neck Flexor Retraining • With stabilizer unit or palpation • Again, start with hold (up to 10 sec) • Then add in gravity (prone)-WATCH for retraction instead of a tuck!! • Then can add in arm movement-penguin reach, Ts, lift ahead

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• Add in throwing if applicable • Scapular punch plus perturbation • Down dog push up with plus • Work on upside down BOSU • Alphabet with weight

• Try some options for working the entire core at once! • Chair pose/squat plus scapular work • Lots of possibilities with plank position • Use physioball roll outs, planks, V ups, etc. • How do we adjust some of these things for our patients who are less physically able?

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• The core should activate prior to any movement (even reaching for the door handle) • Balance training or doing activities with perturbations can be very helpful here • Squats on Bosu • Slide training • Push ups on Bosu • Rebounder work • SLS with perturbations • Balance work on foam pads, etc.

• Commonly seen in the following populations: • Postpartum women (even years postpartum) • Individuals who have lost significant weight (especially those post bariatric surgery or hernia repair) • High impact or heavy lifting athletes

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• Separation of the rectus abdominus to the extent that the linea alba splits under the strain • Can lead to pelvic instability and low back pain • Testing: • Patient in hooklying-ask to raise head and shoulders while reaching toward feet • The clinician measures with fingers/palpation • A separation of 1-1.5 fingers width is considered normal and will resolve spontaneously • If the separation is 2-2 ½ fingers-width or there is a bulge upwards that looks like a mound at midline, special precautions are warranted • Measure depth AND width (depth more important prognostically) • Measure above and below the umbilicus

• Acutely-bracing or splinting for high pressure activities (coughing/sneezing/laughting)-how long/how much do we want to brace the core?? Avoid sit ups/crunches (including sitting up in bed) • Start GENTLE transverse abdominus training right away (some of the early level isometrics and stabilization exercises we have discussed already); you can use manual bracing or Kinesiotape as needed • Slowly move into more advanced/functional positions; note, you are trying to retrain the ability to achieve appropriate IAP, if you notice something that makes you think that is not happening, back down!

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• Upper Split • Teaching to “widen ribs”-pulling the abdominals in/down vs squeezing up/forward • Suggestions • Leg and arm movements on half foam roller • Bridging, quadruped work into planking (with forward translation of weight), rotations • Use of obliques is key (appropriate use!) • Lower Split • Teaching to activate TrA • Variation of positions-quadruped, tandem tall kneeling (try this! It’s harder than you think!), movement oriented, plank oriented work-trying to incorporate obliques and spinal muscles as ready

• Julie Wiebe • Antony Lo-Physiodetective (Youtube) • Evidence In Motion Pelvic Health 6510 weekend course

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• 28 year old male accountant, marathon runner, with insidious onset low back pain x 26 months. No prior history. No prior accidents or surgeries. He played football through high school and also played intramurals in college. Now he plays pick up football but nothing else. Current exercise routine includes marathon training and weightlifting workout 2-3 times per week. He reports that exercise does aggravate his pain, as does sitting for long periods of time and bending over. Easing factors include changing position, pain medication, and heat therapy.

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• What additional subjective information would be helpful? • What would you expect to see in terms of his core with various objective testing? (What presentation do you anticipate) • What would be a good way to educate this very fit individual about his core control problems? • What do you anticipate would be a good place to start with training?

• 44 year old female PSR, chronic history of SI joint dysfunction on and off for the last 8 years. No real mechanism of injury. She has had PT and chiropractic care on and off for the last few years and feels that nothing has really provided lasting benefit. Pain is worse with standing and lifting and especially with transitioning to standing after sitting or lying down for a long time. She doesn’t exercise much, reports occasional walking at this time.

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• What additional subjective information would be helpful? • What would you expect to see in terms of her core with various objective testing? (What presentation do you anticipate) • How would you respond if she asked why therapy might work this time when it has not been successful in the past? • What do you anticipate would be a good place to start with training?

• What questions do you have? Clarifications? • If you think of more later, feel free to contact me anytime: [email protected]

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