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Incorporating Pelvic Floor and Diaphragm Training into Core Programs Margaret Bronson, PT, WCS, CAPP, COMT,CSCS Parkview Outpatient Therapy [email protected] 260-266-4080 Anatomy of the Pelvic Floor “Pelvic Floor” refers to the compound structure which closes the bony pelvic outlet - bony pelvis - pelvic floor muscles - fascia and ligaments -viscera Anatomy of the Pelvic Floor Bony pelvis Pubic arch (pubic symphysis, inferior pubic rami, ischial rami) Ischial tuberosity Ischial spine Coccyx Anatomy of the Pelvic Floor Pelvic floor muscles Pelvic Diaphragm (levator ani) Pubococcygeus Iliococcygeus Coccygeus Puborectalis Associated muscles Piriformis Obturator Internus Anatomy of the Pelvic Floor Anatomy of the Pelvic Floor Function of Pelvic floor muscles Pelvic diaphragm Supports bladder, bowel and uterus in a functional position and assists the closure of the bladder and bowel outlet. It moves the sacrum/coccyx on the pelvis. Stabilizes pelvic ring together with the diaphragm and transversus abdominus to provide trunk and pelvic stability Obturator internus Laterally rotates the hip and lifts the bladder, bowel and uterus into a functional position while assisting in closure of the urethra and anus Interacts with pelvic floor via arcuate tendon to stabilize hip (“rotator cuff of pelvis”) while larger hip muscles move (eg. Squat) Piriformis Laterally rotates the hip. It moves the sacrum on the pelvis in standing. Anatomy of the Pelvic Floor Pelvic ligaments Sacrotuberous ligaments attach the ischial tuberosity to sacrum Sacrospinous ligaments attach spine to sacrum Anatomy of the Pelvic Floor Anatomy of the Pelvic Floor Anatomy of the Pelvic Floor Anatomy of the Pelvic Floor Anatomy of the Pelvic Floor Facilitatory muscles Adductors Gluteals Tranversus abdominus Obturator internus Synergistic muscles Transversus abdominus Deep lumbar multifidus Respiratory diaphragm Anatomy of the Diaphragm Anatomy of the Diaphragm Function of the diaphragm (Ron Hruska, Postural Restoration Institute): Contraction during inhalation increases thoracic volume, drawing central tendon down and dome descends and flattens using external intercostals Relaxation of diaphragm to exhale requires opposition of strong transversus abdominus and internal oblique muscles Weakness of abdominals allow for excessive shortening of diaphragm, with hyperactivity of lumbocostal ligaments, with eventual posterior orientation of diaphragm at posterior linkage with quadratus lumborum and psoas mm During normal inspiration and coughing, real-time MRI demonstrates parallel cranio-caudal movement of the diaphragm and pelvic floor with synchronous changes in abdominal wall diameter. Before inhalation, electrical activity can be observed in the pelvic floor muscles as well as TrA and IO (Talasz, H et al, 2011) Anatomy of the Diaphragm Anatomy of the Diaphragm Anatomy of the Diaphragm Anatomy of the Diaphragm Integrated function of PFM and Diaphragm Pelvic floor muscle activation highest in standing vs sitting, and in standing, higher PFM activation in hypo-lordotic vs normal or hyperlordotic posture. (Capson AC, 2011) Hodges, et al (2007) noted that pelvic floor muscles contribute to postural function of lumbar spine as well as respiratory function due to modulation of intraabdominal pressure. The support of respiration by the pelvic floor muscles is also outlined extensively by Bordoni and Zanier, 2013. Julie Wiebe, PT (juliewiebept.com) had outlined a theory of the pelvic floor piston, working in coordination with other muscles of the core: transversus abdominus and obliques The pelvic floor and diaphragm set up intraabdominal pressure for stability during inspiration, and use of musclular function of TrA, IO and pelvic floor for musculoskeletal lumbopelvic stability during expiration Integrated function of PFM and Diaphragm It should also be noted that the female pelvic floor is a shaped like a dome, not a basin (Hjartardottir, S. et al, 1997). This makes sense, given the wider female pelvic with wider pelvic arch. Julie Wiebe makes the point that the broader shape presents less ability to generate force, and plays a role in core deficiencies in young females after puberty related to ACL disruption. She also states that the male pelvic floor is shaped more like a cone, improving actin/myosin relationship. Anterior weight shift facilitates anterior pelvic floor activation (Julie Wiebe) Performing abdominal drawing in maneoevre during forward stepping increases thickness of TrA and IO, resulting in increased lumbopelvic stability and thus, could increase hip extension during gait (Madkoro, et al 2014) Facilitation of adduction can improve pelvic floor function (extensive coverage through Postural Restoration Institute: highly recommended!) Untrained pregnant and postpartum women were unable to simultaneously contract TrA/IO and PFM when asked to contract PFM or TrA/IO (Pereira, et al 2013) Integrated function of PFM and Diaphragm Prevalence of diastasis recti abdominus in urogynecological population was 52%, with older age, higher gravity and parity, and weaker pelvic floor muscles than those without diastasis rectus abdominus, and 66% of patients with DRA had at least one support-related pelvic floor dysfunction (SUI, FI or POP). Pelvic Floor Dysfunction -Underactive or overactive pelvic floor muscles with probable incoordination of pelvic floor/diaphragm/TrA/IO/glutes system resulting in urinary or fecal incontinence, pelvic organ prolapse or constipation/ pelvic pain -Schettino, et al (2014) studied 105 female athletes and found >65% with SUI and/or urgency, with 70% reporting nocturia, 55% with incomplete bladder emptying and 52% with pelvic pain. Bo et al (2010) looked at 331 former elite athletes and 640 controls and found both former athletes and controls reported SUI at 36%, but that of those athletes that had incontinence during competing in sport (10%), more had UI after competing that those that did not. Integrated function of PFM and Diaphragm http://well.blogs.nytimes.com/2013/09/05/think-like-a-doctor-the-gymnastsbig-belly/ http://well.blogs.nytimes.com/2013/09/06/think-like-a-doctor-the-gymnastsbig-belly-solved/ Physical Therapy for Pelvic Floor Dysfunction Comprehensive history taking and evaluation of pelvic floor musculature and associated musculature Review of bladder diary/ fluid intake/ voiding Assessment of strength, endurance and coordination of PFM Development of individualized plan of care Physical Therapy for Pelvic Floor Dysfunction PFM strengthening for endurance and coordination Education regarding behavioral strategies to improve continence Urge suppression techniques Timed voiding Toileting strategies Bladder irritants discussed Flexibility and strengthening of associated musculature Postural and functional retraining for activities causing dysfunction (sport, sitting, intercourse) Modalities as needed: biofeedback, electrical stimulation Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients DISCLAIMER: The following exercises are suggestions based on the common muscle imbalances found in active female patients with pelvic floor dysfunction. These are not meant to substitute for a comprehensive and individualized evaluation by a pelvic physical therapist. Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Boyle, K. et al, The Value of Blowing Up a Balloon, North American Journal of Sports Physical Therapy. 2010; 5(3): 179-188 Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Integrated function of PFM and Diaphragm Special Populations: Paradoxical Vocal-Cord Dysfunction in Athletes These athletes may present with dyspnea or shortness of breath during exercise, and may not be responding to current asthma medications (or they may present worse than respiratory function tests would deem) Difficulty completing fitness drills Increased emotional stress/ high achiever May have stridor, wheezing, hoarseness, hiccups or other vocal changes Coexisting medical conditions may include exercise-induced asthma, gastroesophageal reflux disease, pharyngeal erythema (secondary to postnasal drip), habitual coughing or throat clearing, and may also present with muscle imbalances and pelvic pain These athletes would benefit from multidisciplinary assessment from speechlanguage pathologist and possibly pelvic floor therapist Applying Concepts to Practice Tomorrow ASK your female athletes about urinary incontinence! It is a dysfunction that indicates muscle dysfunction that can impact their performance today and their quality of life tomorrow. Address what you can based on this presentation, and refer on to pelvic physical therapy when in doubt. If you feel comfortable, ask or use screening form to assess pelvic pain (ability to use tampon, have pelvic gynecological exam or intercourse without pain). Look at posture: pelvic floor, TrA and IO work best with a neutral spine; ensure optimal positioning of trunk during dynamic activities such as running, jumping, squatting. Assess diaphragm function through posture and respiration: do they have stiff thoracic spine inhibiting contraction/descent of diaphragm? Are abdominal muscles able to contract to elevate diaphragm? Can they blow a balloon? Do they hold breath during exertion portions of sport? Do they have other signs of diaphragmatic/ vocal-cord dysfunction such as voice hoarseness, stridor, soft voice, or hiccups? Refer to or contact speech-language pathologist for further evaluation. Don’t be afraid to stop offending activity for short time while working on muscle imbalances: try substituting uphill walking for running to improve pelvic floor coordination with TrA/IO Look, listen, feel… Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Any Questions??? Integrating Pelvic Floor, Diaphragm and Core in Your Athletes/Patients Thank you for listening and participating in this Breakout Session! [email protected] if you have any other questions regarding your patients/clients